
Class. 
Book 



COPYRIGHT DEPOSIT 



A SYSTEM 



OF 



MIDWIFERY, 



INCLUDING THE 



DISEASES OF PREGNANCY AND THE PUERPERAL STATE. 



/ BY 
WILLIAM LEISHMAN, M.D., 

REGIUS PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF GLASGOW; PHYSICIAN TO THE 

UNIVERSITY LYING-IN HOSPITAL; FELLOW AND LATE VICE-PRESIDENT OF THE 

OBSTETRICAL SOCIETY OF LONDON; CORRESPONDING MEMBER OF THE 

OBSTETRICAL SOCIETY OF EDINBURGH, AND OF THE 

OBSTETRICAL AND GYNAECOLOGICAL SOCIETY 

OF BERLIN, ETC., ETC., ETC. 



SECOND AMERICAN FROM THE SECOND AND REVISED ENGLISH 

EDITION 



WITH ADDITIONS BY 

JOHN S. PA KEY, M.D., 

OBSTETRICIAN TO THE PHILADELPHIA HOSPITAL; VICE-PRESIDENT OF THE OBSTETRICAL 
SOCIETY OF PHILADELPHIA, ETC. 





PHILADELPHIA: 

HENRY C. LEA. 

18 7 5. 






Entered according to Act of Congress, in the year 1875, 

By HENRY C. LEA, 

In the office of the Librarian of Congress, at Washington, D. C. 



SHERMAN & CO., PRINTERS, PHILADELPHIA. 



o- 




EDITOR'S PREFACE. 



In preparing for the press the Second American Edition of Dr. 
Leishman's System of Midwifery the Editor has added such notes only 
as he believed would make the book more useful to the profession 
in this country. The additions are distinguished from the text by 
being inclosed in brackets, [ — P.], and will be found chiefly in the 
chapters on the Use of the Forceps, Lactation, and the Puerperal Dis- 
eases. A chapter on Diphtheria of Puerperal Wounds has been added, 
and a few new illustrations have been introduced, representing the 
principal modifications of Obstetrical Instruments generally employed 
in this country. 

The Editor trusts that these additions will increase the usefulness of 
a work of which the value is attested by the simultaneous exhaustion 
of both the English and American Editions. 

J. S. P. 
1513 Arch Street, Philadelphia, 
December, 1875. 



PREFACE TO THE SECOND EDITION. 



The success which has attended the publication of this Work may, 
it is hoped, be accepted as an indication that it has, in some degree, 
fulfilled the purpose with which it was designed. 

In the present Edition, many errors have been corrected, and no 
effort has been spared to render it more worthy of the approbation 
which has been accorded to it. The chief alterations will be found in 
the Physiological Section — in regard to which the Author is under 
great obligation to his colleague, Professor Allen Thomson — and in the 
chapters on Puerperal Fever, which have been re-written, with the 
view of giving greater prominence to the doctrine of septicemic 
infection. 

The assistance of Dr. Gavin P. Tennent has again been invaluable, 
and especially so in the rearrangement of a Copious Index. 

11 Woodside Crescent, Glasgow, 
October 1st, 1875. 



PREFACE TO THE FIRST EDITION. 



The Author's object in this Work has been to furnish the Students 
and Practitioners a Complete System of the Midwifery of the present 
day. Its claim to a title so ambitious may be questioned. 

Of English Text-Books, some of the very best have long been out 
of print; some are out of date; and others arc mere Handbooks, in 
which the subject is, however ably, but cursorily treated. In our 
language, scarcely a modern work exists which can be compared with 
those of Cazeaux and Scanzoni. This is the Author's apology for an 
attempt in which, while he does not presume to emulate those authors, 
he ventures to hope that the fruit of some earnest labor, but too scant 
leisure, may not be held unworthy of consideration. 

There are, he believes, few modern works of approved merit, whether 
British or Foreign, with which the Author has not made himself 
familiar; nor has he scrupled to avail himself from these sources, of 
what seems to him, at any point, to contribute to the elucidation of the 
subject. In no case, it is hoped, has this been done without ample 
acknowledgment. 

The meagreness of statistical details, references, and illustrative 
cases, is a part of the original plan, adopted with the view, as far as 
the subject will admit, of maintaining the narrative form. 

To several of his colleagues, to many professional friends, and, 
especially, to Dr. Gavin P. Tennent, for assistance in passing the work 
through the press, the Author is under obligations which he cannot 
too warmly acknowledge. 

4 Montague Place, Glasgow, 
July 1st, 1873. 



CONTENTS. 



CHAPTEE I. 

INTRODUCTORY. 

History of Midwifery — Hippocratic Era — Arabian School — Ambroise Pare — Mau- 
riceau — English Midwifery — Objections to the Practice of Midwifery considered 
— Comparative Anatomy of the Pelvis — The Pelvis a Tube through which the 
Product of Conception Passes — Parturition in the Primates; in the various 
Paces — The Erect Posture the Main Cause of Comparative Difficulty in the 
Human Species — The Human Pelvis a Curved Canal — Separation of Pelvic 
Articulations during Labor — Midwifery Defined, 17 

CHAPTER II. 

THE PELVIS. 

Oslnnominatum : Sacrum: Coccyx — The Pelvis as a Whole : " True " and " False " 
— Difference between Male and Female Pelvis: at Brim; in Cavity; and at 
Outlet — Pelvic Articulations: (a) Pelvi-lumbar ; (b) Sacro-Coccygeal ; (c) Sac- 
roiliac; (d) Symphysis Pubis; (e) Obturator Ligaments; (/) Sacro-Sciatic 
Ligaments — Inclination of Pelvis — Axis of of the True Pelvis — Brim or Inlet 
— Cavity — Outlet — Pelvic Diameters— Pelvic Angles — Development of Pelvis 
— Certain Soft Parts connected with Pelvis ; Obturator Internus and Pyriformis 
Muscles; " Floor » of Pelvis, 33 

CHAPTER III. 

FEMALE ORGANS OF GENERATION. 

A. External. Labia; Perineum; Hymen, etc. — Erectile Tissue — The Vagina — 

Glands of the External Organs— Abnormal Conditions — Mammary Glands. 

B. Internal. The Uterus : Situation of; Divided into Body and Cervix; Axis 

of Unimpregnatcd Uterus ; Cavity of; Fundus; Surfaces and Borders ; Serous 
Covering of — Broad Ligaments; Round Ligaments; Vesico-Uterine Folds — 
The Fallopian Tubes — Parovarium — Folds of Douglas — Equilibrium of the 
Uterus, 48 

CHAPTER IV. 

female organs of generation (Continued). 

Of the Proper Tissue of the Uterus — Of the Mucous Layer : its Structure and Glands, 
in the Body and Cervix — Bloodvessels of the Uterus — Lymphatics and Nerves 
— Malformations and Abnormal Conditions— The Ovaries : their Structure — 



Vlll CONTENTS. 

The Graafian Vesicles and their Development — The Ovum — Phenomena of 
Ovulation — Formation of the Corpus Luteum — The Corpus Luteum of Preg- 
nancy distinguished, 67 

CHAPTEE V. 

MENSTRUATION AND CONCEPTION. 

The "Rut" of Mammalia: Analogy between this and Menstruation — The First 
Menstrual Period: Statistics of Duration of a " Period "—Quantity of the 
Discharge — Menstruation a Hemorrhage : Non-Coagulability of — Source of 
the Menses: various Theories regarding : is from the Mucous Membrane of the 
cavity — Pouchet's Theory examined ; is the Mucous Membrane shed ? — Views 
of Kolliker, Coste, etc. — Duration of Childbearing Epoch — Cause of Men- 
struation — Conception — Composition of the Semen — Spermatozoa and their 
development — " Sperm Cells " — The function of the Germinal Vesicle ; " Germ 
Cells " — How does the Semen reach the Ovum? 87 

CHAPTER VI. 

DEVELOPMENT OF THE OVUM. 

Formation of the Embryo-cell — Cleavage of the Yolk — Development of Blasto- 
dermic Vesicle — "Serous" and "Mucous" Layers — The Area Germinativa 
and Primitive Trace — Formation of the Embryo ; of the Umbilical Vesicle and 
Omphalo-mesenteric Vessels; of the Amnion; of the Allantois and Umbilical 
Vessels; of the Chorion — The Liquor Amnii — The Vitriform Body — The 
Decidua : what is it? — Decidua Vera; Eeflexa ; Serotina — Early connection 
of Ovum with Decidua — The Umbilical Cord : Vessels; Gelatin of Wharton, 
etc. — Knots on Cord — The Placenta in Birds: in Non-Placental Mammals: 
in Ruminants: in Man : Maternal and Foetal Surfaces of: Maternal Circula- 
tion in : Curling Arteries: Sinuses: Veins — Foetal Portion: Arteries: Tufts 
or Villi : Veins — Functions of the Placenta — Structure of Villi, . . 101 

CHAPTER VII. 

DEVELOPMENT OF THE EMBRYO AND FOETUS. 

Demonstration of Embryonic Structures — Characteristics and Development of the 
Foetus at the termination of each Month of Pregnancy, from the third onwards 
— Dimensions of Mature Children — Of the Presentation and Attitude of the 
Child in the Womb— Causes of Cranial Presentation : theories of " Physical 
Gravitation," " Volition," and " Reflex Action " — The Foetal Cranium : 
Sutures: Fontanelles: Diameters — Definition of the term "Vertex" — Func- 
tions of the Foetus: Circulation: Respiration: Nutrition: Secretion, . 120 

CHAPTER VIII. 

PREGNANCY : SIGNS OF PREGNANCY. 

Pregnancy — The Gravid Uterus : Muscular fibres of: Muscular layers — Change in 
fibres after delivery — Development and Anatomical Relations of Uterus at 
various stages of Pregnancy — Signs of Pregnancy — Suppression of the Cata- 
menia — Digestive Disorders: Morning Sickness: Salivation — Kiestein — 
Changes in the Mammae : Pain: Enlargement: Secretion of Milk: Areola: 
Changes in Nipple, and in Glandular Follicles : Secondary Areola — Enlarge- 



CONTENTS. IX 

ment and External Appearance of Abdomen : Flattening in early months : 
Change in the Appearance of Umbilicus: Diagnosis of other Abdominal 
Tumors— Vaginal Examination: Color: Digital Examination: Vaginal 
Pulse, 144 



CHAPTER IX. 

signs of pregnancy (Continued). 

Changes in the Os and Cervix Uteri : Progressive Softening of: Characters of at 
Various Stages — Position of Os in Relation to Pelvic Walls — Practice of the 
"Toucher" — Examination per Anum — Quickening: Ecetal Movements Ob- 
served ; («) by the Mother, (b) by the Accoucheur — Ballottement or Repercus- 
sion — Foetal Pulsation — Funic Souffle — Uterine Souffle : Theories as to its Pro- 
duction — Stethoscopic Examination of Foetal Movements — Signs divided into 
Certain and Probable — Tabular Resume of the Signs of Pregnancy, . 159 

CHAPTER X. 

DURATION OF PREGNANCY — SUPERFCETATION. 

Duration of Pregnancy : in Cows and Mares : in Women — Protracted Preg- 
nancy : Cases of — Difference in Rate of Development — Mode of Calculating 
the Probable Time of Delivery: Calculation from last Menstruation to be cor- 
rected by Period of Quickening — Superfcetation : to be distinguished from 
Superfecundation — Proofs of the latter — Twin Pregnancy in relation to this 
Subject — Cases — Conclusions, . . . , . „ , . .176 



CHAPTER XI. 

PLURAL* PREGNANCY — EXTRA-UTERINE PREGNANCY. 

Plural Pregnancy — Mode of Impregnation — Twins: Disposition of the Mem- 
branes and Placenta in : Diagnosis of : Relation of to Superfcetation — Triplets, 
etc. — Extra- Uterine Pregnancy — Varieties of: Ovarian: Tubal: Tubo- 
Ovarian: Abdomino-Tubal: Tubo-Uterine, etc.: Abdominal — Causes of Extra- 
Uterine Pregnancy — Development of the Ovum and its Coverings — Sympathy 
of the Uterus — Symptoms — Progress of in Different Varieties : Rupture of the 
Sac: Peritoneal Inflammation: Discharge of Foetal Debris — Terminations — 
Treatment, 190 



CHAPTER XII. 

abnormal development. 

Molar Pregnancy — False Moles : from Vagina : Membranous Dysmenorrhoea : 
Fibrous and Hemorrhagic Casts of Uterus — True Moles : Fleshy Moles : Hy- 
datidiform Moles — Their Pathology, Diagnosis, and Treatment — Diseases of the 
Placenta, and their Effects — Missed Labor — Diseases of the Foetus — Infra- 
Uterine Fractures and Amputations: Efforts at Reproduction — Monsters, 205 



X CONTENTS. 

CHAPTEK XIII. 

DISEASES OF PREGNANCY. 

I. Disorders of the Digestive Functions — Excessive Vomiting: Treatment 
of: Question of Induction of Premature Labor in — Anorexia — Gastrodynia — 
Pyrosis — Constipation — Diarrhoea — II. Disorders of Respiration — Dysp- 
noea—Cough — III. Disorders of the Circulation— Condition of the Blood 
in Pregnancy: Diminution of Blood-Corpuscles : Proportional Alteration in 
Fibrin and Albumen — Supposed resemblance of the Phenomena of Pregnancy 
to those of Chlorosis — Administration of Iron in Pregnancy — Plethora — 
Varicose Veins — Haemorrhoids — Thrombus of the Vagina, . . . 218 



CHAPTER XIV. 

diseases of pregnancy (Continued). 

IV. Disorders of Secretion and Excretion — Ptyalism — Interference with 
Function of Kidneys and Bladder — Retention : Mechanical or from Paralysis 
— Albuminuria : State of the Blood in : Peculiarities of the Puerperal Form: 
Connection of with Puerperal Convulsions : Symptoms, Prognosis, and Treat- 
ment — The Phosphatic Diathesis in Pregnancy — Leucorrhcea and Granular 
Vaginitis — Ascites — Dropsy of the Amnion — Hydrorrhea — V. Disorders 
affecting Locomotion — Pelvic Articulations : Relaxation of: Inflammation 
of— VI. Disorders affecting the Nervous System— Affections of the 
Special Senses — Effect on the Moral and Intellectual Faculties — Abdominal and 
Uterine Pain— VII. Displacements of the Gravid Uterus — Prolapsus — 
Anteversion and Anteflexion: Symptoms and Treatment of — Retroversion; 
how caused originally: Chronic and Acute Forms : Symptoms and Treatment 
of each : Operation for the Reduction of — Oblique Displacements, . . 232 

CHAPTER XV. 

LABOR AND ITS PHENOMENA. 

Causes of Labor — Maturity: Antagonism between certain Groups of Uterine 
Fibres: Brown-Sequard's Theory : Labor coincident with the Tenth Menstrual 
Period — Forces by which Delivery is effected : Nervi-motor Functions of the 
Uterus: Effect of Emotional Causes: Reflex Function of the Spinal Cord: 
Peristaltic Action : Auxiliary Force in the Muscles of Expiration — Stages 
of Labor— Preparatory Stage— First Stage: Labor Pains; their Effects on 
the Maternal Pulse and on the Uterine Souffle: False Pains: Mechanism of 
the Dilatation of the Os ; the Bag of Waters ; Effect of Longitudinal Fibres : 
Termination of First Stage in Rupture of Membranes : Rigor : Show— Second 
Stage : Change in character of the Pains ; the " Caput Succedaneum :" Action 
of Voluntary Muscles : Dilatation of the Perineum : Birth of the Head and 
Trunk— Third Stage : "Dolores Cruenti :" Separation and Expulsion of the 
Placenta ; Mechanism of this, ........ 252 

CHAPTER XVI. 

MANAGEMENT OF NATURAL LABOR. 

Duties of the Accoucheur — Preliminary Arrangements — False Pains and their Treat- 
ment — Armamentarium of the Accoucheur — Position of the Woman during 



CONTENTS. XI 

Labor — Digital Examination : Points to be examined — The Patient not to take 
to bed during the First Stage — Preparation of the Bed, etc. — Abdominal 
Muscles to be called into play during the Second Stage — Management of the 
Anterior Lip of the Os — Obstacles arising from Rigid Os ; and from Non- 
Rupture of Membranes — Use of Stethoscope — Views regarding Support of 
Perineum — Treatment if Laceration is threatened — Causes of Laceration — 
Birth of the Head — Passage of the Trunk — Treatment of Suspended Animation 
in the Child — Ligature of the Cord — Management of the Third Stage: Crede's 
Method — Application of Abdominal Bandage — Treatment of the Woman after 
Delivery, 268 

CHAPTER XVII. 

THE MECHANISM OF LABOR. 

Ideas which Labor involves — Difficulty and Importance of the Subject — Historical 
Sketch: Views of Sir Fielding Ould ; of Smellie; of Saxtorph ; of Solayres de 
Renhac ; and of Naegele — Natural and Faulty Presentations — Cranial Presen- 
tations : Occipito-Anterior and Occipito-Posterior Varieties — First Posi- 
tion: Pelvic Obliquity: Occipito-Frontal Obliquity, or Flexion: the Head 
"at the Brim :" Examination of Fontanelles and Sutures — Rotation ; Causes of 
— The "Presentation" or "Presenting Point" — The Caput Succedaneum — 
The Chin leaves the Chest — Further Descent and Birth of the Head — Obliquity 
at the Outlet — Moulding — External Rotation or Restitution of the Head — 
Second Position: the Converse of the First — Third Position — Resume of 
Mechanism in Occipito-Anterior Positions, 284 



CHAPTER XVIII. 

mechanism of labor (Continued). 

Occipito-Posterior Positions — The Third [Fourth] Cranial Position ; Rotates 
into the Second, or may terminate with forehead forwards — The Fourth [Fifth] 
Position ; Rotates into the First, or may terminate with Forehead forwards — 
Artificial Rectification of these Positions [Sixth Position] — Comparative Fre- 
quency of the Four Cranial Positions. 

Face Presentations — Distinction between "Obstetrical" and "Anatomical" 
Face — Mento-Posterior and Mento-Anterior Varieties— Fourth Position: 
Mechanism of— Third Position — First Position ; Rotates into the Fourth 
— Second Position : Rotates into the Third — Relative Frequency of the Facial 
Positions — Operative Interference in — Irregular Presentations — Tabular Com- 
parison of Cranial and Facial Positions, 303 

CHAPTER XIX. 

PELVIC PRESENTATIONS. 

The Practice of the Past — The Pelvis a Natural Presentation — Dorso-Anterior and 
Dorso-Posterior Positions — Breech Presentation ; Four Positions of — First 
Position of the Breech: Rotation: Passage of the Buttocks: Descent and 
Birth of the Shoulders: Difficult Progress of the Head, and Mechanism of its 
Expulsion — Second Position of the Breech — Third Position of the 
Breech : Birth of the lower portion of the Trunk, and of the Shoulders i 



Xll CONTENTS. 

Kotation of the Face backwards, and Mechanism of the Birth of the Head; 
Exceptional Terminations— Fourth Position of the Breech— Special Kisk 
of Pelvic Presentations — Diagnosis and Peculiarities — Knee and Footling Cases 
— Management of Pelvic Presentations — Nature of Assistance to be Rendered — 
Use of the Fillet, Yectis, and Blunt Hook — Indiscriminate Dragging on the 
Lower Limbs to be avoided — Treatment of Case where Arms pass up along- 
side Head — Management of the Funis — Indications of impending Death of the 
Child — Manipulation for effecting speedy Delivery of the Head — Use of the 
Forceps, 324 

CHAPTER XX. 

transverse presentations: complicated presentations. 

Transverse Presentations — The Arm or Shoulder the Presenting Part — Causes 
of — Signs of, before and during Labor — Premature Rupture of the Membranes 
to be avoided^-Dorso-Anterior and Dorso-Posterior Positions — Determination 
of exact Position by Observation of the Hand — Probable Course of an Unaided 
Case — Occurrence of Spontaneous Evolution — Spontaneous Expulsion — Methods 
of Operative Assistance : Period of Labor to be selected : Cephalic Version : 
Podalic Version : Method of Combined External and Internal Manipulation: 
Special Difficulties — Procedure Modified if Child Dead— Compound or Com- 
plicated Presentations — Hand and Head— Hand and Feet, etc.— General 
Management of these, .......... 341 

CHAPTER XXI. 

FUNIS PRESENTATION. 

" Presentation " and " Prolapse" of the Cord — Relation of the Funis to other Pres- 
entations — Causes of — Symptoms of at Various Stages of Labor — Great Danger 
to Child— Treatment: at first Expectant: avoid Rupture of the Membranes : 
Reposition by the Fingers : by Mechanical Appliances : Various Repositoria 
described: Postural Method : Use of the Forceps : Turning, . . 355 

CHAPTER XXII. 

PREMATURE EXPULSION OP THE OVUM. 

Classification — Abortion ; Definition of — Causes : in General Health : from Reflex 
Irritation: from Diseases of the Ovum: from Action of Oxytoxics: from Af- 
fections of Neighboring Organs : from Mechanical Violence — Tendency to 
Repeated Abortion — Symptoms ; at various Periods— Precursory Symptoms : 
Pains : Hemorrhage— To be distinguished from Delayed Menstruation— Signs 
of Death of the Foetus — Distinction to be drawn between "Threatened" and 
" Inevitable " Abortion — Retention of the Ovum — Expulsion of the Placenta — 
Treatment: Preventive: Prevention when Abortion Threatened — Expulsion to 
be Promoted when Inevitable — Management of Haemorrhage, and of the Pla- 
centa: Placental Forceps — Treatment of a Woman after Abortion — Prema- 
ture Labor — Special Causes— Treatment, 367 

CHAPTER XXIII. 

HEMORRHAGE before delivery. 

"Unavoidable" and "Accidental" Haemorrhage — Placenta Previa; Central 
and Lateral : Original Idea as to the nature of: Views of Roederer and Rigby 



CONTENTS. Xlll 

— Causes of Placental Presentation — Symptoms :. Hemorrhage before and 
during Labor : Examination from the Vagina : Occasional Termination by- 
Expulsion of the Placenta, with Cessation of Haemorrhage : Symptoms and 
Termination of the " Lateral " Variety — Treatment: General Measures: Use 
of the Plug or Tampon : Evacuation of the Liquor Amnii by Puncture of the 
Membranes or Placenta — Turning in Placenta Prsevia : Passage of the Hand 
through the Placenta at one time Practiced: Usual Method of Operation — The 
Bi-Polar Method — Artificial Extraction of the Placenta: Simpson's Statistics 
— Partial Separation of the Placenta: Barnes's Views — General Conclusions as 
to Treatment — Accidental Hemorrhage; more serious than is generally 
supposed — Site of the Placenta — Symptoms — Treatment — Use of Styptics in 
both Forms of Haemorrhage, . . . . . . . ' . 386 

CHAPTEE XXIV. 

HAEMORRHAGE AFTER DELIVERY. 

Haemorrhage in the Third Stage of Labor — Abnormal and Ketained Placenta, and 
Irregular Uterine Contraction, as Causes of Flooding — Post-partum Hemor- 
rhage — Causes; General and Local — Symptoms; of External and Internal 
Haemorrhage: Examination of the Abdominal "Walls: Examination by the 
Vagina : General Symptoms : Symptoms which indicate the Approach of 
Death — Treatment; Prevention: Treatment during the Hemorrhage: Pres- 
sure and Friction over the Uterine Kegion — Effects of Bandaging — Effect of 
Passing the Hand into the Uterine Cavit}' — Application of Cold, should not be 
Continuous — Astringents to Internal Surface — Galvanism — Ergot — Treatment 
by Plugging abandoned — Views in regard to Compression of the Abdominal 
Aorta — Application of the Perchloride of Iron and other Styptics : Objections 
to, and Arguments in favor of this Procedure — Dr. Barnes's Process — Treat- 
ment directed to the General Condition of the Patient — Effects of Rest and 
Position — Reaction to be avoided after severe Flooding — Transfusion : The 
"Mediate" and " Immediate " Processes: Dr. Aveling's Apparatus; Injec- 
tion of Defibrinated Blood, and of Saline Solutions, ..... 404 

CHAPTER XXV. 

INVERSION OF THE UTERUS. 

Varieties of Inversion : Three Stages of the Ordinary Variety — Inversion of the 
Unimpregnated Uterus — Inversion usually occurs during the Third Stage of 
Labor — Causes: Dragging upon the Cord: Shortness of the Cord : Irregular 
Contraction of the Uterus — Connection of this Accident with Hour-Glass Con- 
traction — Effects of Paralysis of the Fundus — Mechanism of the Displacement 
— Symptoms: Peculiar Violence of the Shock: Haemorrhage: Absence of Tu- 
mor in Hypogastrium — To be distinguished from a Fibrous Polypus — Sensibil- 
ity and Occasional Contractility of the Tumor — Modes of proving the Absence 
of the Uterus from its Normal Situation — Recurrence of Haemorrhage in 
Chronic Inversion — Treatment: Ordinary Method of Replacement : Manage- 
ment of the Placenta if still Adherent: Management of more Difficult Cases: 
Compression of Tumor: Depaul's Instrument — Chronic Inversion: Mont- 
gomery's Method of Reposition: Constriction of the Os must be Overcome: 
Effects of Sustained Elastic Pressure — Division of the Stricture : Removal by 
the Ecraseur — Thomas's Operation as substitute for removal, . . . 418 



XIV CONTENTS. 

CHAPTER XXVI. 

RUPTURE OF THE UTERUS. 

Rupture during Pregnancy — Rupture during Labor — Partial or Incomplete Rup- 
ture — Site, Extent, and Direction of the Laceration — Reason of the Compara- 
tive Frequency of Cervical Rupture — Is Rupture less common in Primiparae? 
— Effect of the Duration of Labor — Causes — A. Mechanical : Sex ; Pelvic De- 
formity ; Faulty Presentation ; Pressure upon the Cervix ; Operative Vio- 
lence ; Effect; Violent Uterine Action — B. Reflex: Excitement of Cervix, 
etc. — C. Pathological: Cancer; Rigidity of the Os ; Thinning or Partial 
Atrophy; Softening; Fatty Degeneration — Symptoms — Premonitory: Local- 
ized Pain increased during Labor — Signs of Rupture: Pain; Haemorrhage; 
Shock; Recession of the Presenting Part — Laceration involving the Vagina — 
Treatment — Preventive Measures : Delivery by the Forceps or b}' Perforation 
— Extraction of the Placenta — Hernia of the Intestine — If Foetus has escaped 
into the Peritoneal Cavity, Turning recommended : Gastrotomy is, however, 
to be preferred — Further Management of the Case — Treatment of Rupture of 
the Uterus in various Stages of Pregnancy, 430 

CHAPTER XXVII. 

DEFORMITIES OF THE PELVIS. 

Importance of the Subject — Classification of Deformities — Causes — Diseases affect- 
ing the Pelvis : Rachitis: Malacosteon — Rickets and Malacosteon contrasted : 
Nature of the Brim Deformity characteristic of Each — Possibility of Yielding 
in a Malacosteon Pelvis — The Obliquely Distorted Pelvis — Deformities of the 
Cavity : Flattening of the Sacrum : Funnel-shaped Pelvis — Distortion of the 
Outlet : Approximation of the Tuberosities of the Ischia : Projection Forwards 
of the Coccyx : Anchylosis of the Sacro-coccygeal Articulation — Masculine 
Type of Pelvis — Infantile Type — Effect of Muscular Action in producing 
Pelvic Distortion— Spondylolisthesis — Pelvis JEquabilker-justo-Major, and 
justo-Minor — Obstruction from Exostosis, O.-teo-Sarcoma, and other tumors, 
and from Fractures of the Pelvis, and Morbus Coxarius — Symptoms — Measure- 
ments of the Pelvis: Pelvimeters — Examination by the Fingers — Effects of 
Distortion — Difference between "Impaction" and "Arrest" — Treatment — 
Prevention — Circumstances which call for the Forceps, Turning, Craniotomy — 
Use of the Forceps in Deformed Pelvis — Caesarian Section, . . . 443 

CHAPTER XXVIII. 

THE FORCEPS. 

History of the Forceps — Chambei-len's Forceps — Invention of the Pelvic Curve — 
The Short Forceps: Cases to which it is Applicable — Reasons for preferring the 
Straight Forceps in most Cases — Forceps in Use in America— Circumstances 
in which the Forceps is Required — Application of the Forceps : Conditions 
essential to safety: Degree of Dilatation of the Os : Is it necessary to feel an 
Ear ? Membranes to be ruptured : Blades to be applied to the Sides of the- 
Head : Forceps to be applied in the Opposite Oblique Diameter to that occupied 
by the Head of the Child — The Operation : Introduction of the " Lower " and 
" Upper" Blades in the First Cranial Position — Application to the other Cra- 
nial Positions, 460 



CONTENTS. XV 

CHAPTER XXIX. 

the forceps (Continued). 

Action of the Forceps: 1, by Compression; 2, by Traction; 3, by Double-Lever 
Action — Mode of Extraction: Management and Direction of the Handles at 
various Stages of Delivery — Delivery by the Forceps in Occipito-Posterior 
Positions : Rotation by the Forceps : Extraction with the Forehead Forwards 
— The " Long Forceps " — Reasons for Preferring the Pelvic Curve in this Ope- 
ration — Description of the Instrument — Cases in which the Long Forceps is 
applicable — Directions for the Operation : Blades to be applied to the Sides of 
the Pelvis: Mode of Introduction of the Lower and Upper Blades: Relation 
of the Blades to the Surface of the Cranium — Use of the Forceps in Presenta- 
tions of the Face — Procedure when the Head is retained after Expulsion of the 
Trunk — Modifications of the Instrument : Ziegler's, Radford's, and other For- 
ceps, 479 

CHAPTER XXX. 

THE VECTIS; FILLET; BLUNT HOOK; ETC.: DECAPITATION. 

Discovery of the Vectis by Roonhuysen : Mode of Using the Vectis — Cases to 
which it may be Applied — The Fillet ; a Contrivance of Ancient Origin ; 
Applicable chiefly to Breech Cases — The Blunt Hook — The Crotchet : Pre- 
cautions necessary in the Use of the Crotchet: The Guarded Crotchet — Use of 
two Crotchets — Decapitation ; Various Instruments for : Description of the 
Operation : Extraction of the Trunk : Subsequent Extraction of the Head by 
the Various Methods of the Forceps, Crotchet, or Cephalotribe, . . 500 

CHAPTER XXXL 

TURNING. 

Various Methods of Turning: Turning as practiced by the Ancients: Podalic 
Version — Circumstances which call for and Conditions favorable to the Opera- 
tion : The Operation in Detail : Choice of Hands : Introduction of the Hand : 
Passage of the Os : Seizure of a Foot or Knee — Circumstances which render 
Turning Difficult: Difficulty in Seizing the Foot — Child to be Turned For- 
wards — Management of the Case after Version — Pelvic Version — Cephalic 
Version — Turning in Contracted Pelvis: Degree of Distortion which may 
admit of Turning — Turning contrasted with the Long Forceps, and. as a Sub- 
stitute for Craniotomy — Special Difficulties — Bimanual or Bipolar Version : 
Processes of Wigand, Lee, and Braxton Hicks, 510 

CHAPTER XXXII. 

EMBRYOTOMY. 

Conditions which warrant the Operation — Craniotomy : consists of Various Stages 
— Perforation: Varieties of Perforators: Method of, and Precautions to be 
Observed in Perforating — Cranial Contents to be Broken Up and Dislodged — 
Traction to be now Employed — Use of the Crotchet : where to Fix it : Dangers 
of — The Guarded Crotchet — The Craniotomy Forceps — Removal of the Vault 
of the Cranium — Protection of the Maternal Tissues — Davis's Osteotomist — 



XVI CONTENTS. 

The Scalp to be Preserved — Turning after Craniotomy — Canting the Base, after 
Eemoval of the Flat Bones, .and bringing the Face Downwards — The Cepha- 
lotribe: French and English Models — Cephalotripsy the Final Stage in the 
Operation of Craniotomy — Details of the Operation — May the Cephalotribe be 
used as a Tractor? — Subsequent Extraction of the Trunk — Craniotomy in 
Breech Delivery, after the Passage of the Trunk — Embryulcia: Evisceration 
of the Foetus: applicable chiefly to Impacted Transverse Presentations — Van 
Huevel's Forceps Saw — Dr. Barnes's process of Cranial Section by the Ecra- 
seur, 526 

CHAPTER XXXIII. 

HYSTEROTOMY and allied operations. 

History of the Operation of Hysterotomy — Cases in which it is Justifiable: Mater- 
nal Mortality : Different Results in British and Continental Practice — Conditions 
favorable to Success — The Operation and its Details: Duties of the Assistants: 
Closure of the Wounds — After-Treatment — Causes of Fatal Result — Effect of 
Cold in preventing Peritonitis — Repeated Success of the Operation in the same 
Cases — G-astrotomy : Cases in which the Operation is required — The so-called 
Vaginal Caesarian Section— Symphysiotomy : History and Nature of this 
Operation : Objections to it — Stoltz's Operation of Pubiotomy — Tabular State- 
ment showing the Degree of conjugate Contraction at the Brim which may be 
supposed to indicate respectively the Operations of the Long Forceps, Turning, 
Embryotomy, and the Caasarian Section, ....... 545 

CHAPTER XXXIV. 

induction or premature labor. 

History "of the Subject — Nature and Scope of the Operation — Viability or Non- 
Viability of the Child — Conditions which justify the Operation — Various 
Methods of Provoking Uterine Action: Ergot: Puncturing the Membrane: 
Separation of the Membranes by Hamilton's Method : Dilatation of the Cervix 
by Tents : Introduction of an Elastic Bougie or Catheter into the Uterus : 
Plugging or Distending the Vagina: The Method of Kiwisch by the Vaginal 
Douche: Cohen's Method by Irttra-uterine Injections: Dr. Barnes's Process, 
consisting of a " Provocative " and an " Accelerative " Stage : Galvanism : Ir- 
ritation of the Breasts — Anatomical and Physiological Fitness of the Parts — 
Constitutional Influences, .......... 558 



CHAPTER XXXV. 

labor obstructed by maternal soft parts. 

Rigidity of the Os : Use of Belladonna : Forcible Distension : Incision of Os Oc- 
cluded — Effects of Uterine Displacement — Abnormal Conditions of the Vulva 
and of the Vagina: Rigidity : Persistent Hymen : Cicatrices from Sloughing : 
Treatment of these Conditions — Vaginal Thrombus — Uterine Polypus : Man- 
agement of, where it obstructs Labor — Ovarian Tumors — Fcecal Accumulation 
in the Rectum : Rectocele — Distension of the Bladder : Cystocele — Stone in the 
Bladder an Occasional Impediment — Hernial — Other Tumors which may im- 
pede Labor — Malignant Disease of the Canal, 570 



CONTENTS. XV11 

CHAPTER XXXYI. 

OBSTRUCTION DEPENDING ON THE STATE OF THE OVUM. 

Hydrocephalus: Diagnosis of: Management of such Cases — Spina Bifida — Obstruc- 
tion from Ascites, Hydrothorax, and Distension of the Bladder — Gaseous Dis- 
tension from Putrefaction — Tumors springing from the Foetus — Anchylosis of 
the Joints, and Intra-uterine Fracture — Premature Closure of the Sutures — 
Unusual Development of the Foetus — Special Difficulties in Plural Pregnancy: 
Locked Twins — Monsters which impede Delivery ; The Siamese Twins, and 
other Similar Cases — Shortness of the Umbilical Cord as an Obstacle — Dorsal 
Displacement of the Arm — Thickness and Persistence of the Membranes, 582 

CHAPTER XXXVII. 

UTERINE INERTIA. AND PRECIPITATE LABOR. 

Irregularities in the Progress of Labor ; often due to Intestinal Derangement — 
Inertia : Influence of Temperament, Climate, Age, Emotion, Excessive Dis- 
tension, Premature Rupture of the Membranes, etc. — Influence of Irregular 
Uterine Action ; Uterine Tetanus — Wigand's Classification : Different Grades 
and Varieties of Inertia — Treatment of Inertia ; if from Over-distension or 
Displacement of the Uterus ; if from Intestinal Derangement — Various Modes 
of Exciting Reflex Uterine Energy — Stimulants as a rule to be avoided — Use of 
the Forceps in Inertia — Ergot ; its Natural History, and Physiological Effects : 
Rules for its use in Midwifery — Other Oxytoxic Agents — Precipitate Labor: 
Causes obscure : Apparent Connection with Menstrual Excitement — Labor may 
be Precipitate from Deficient Resistance — Danger of Rupture and Laceration 
of the Uterus — Tendency to Post-partum Haemorrhage — Treatment: Empty 
Bowels : Opium : Sources of Reflex Irritation to be carefully avoided, . 594 

CHAPTER XXXVIII. 

THE PUERPERAL STATE : LACTATION. 

Management of the Puerperal State — The Lochia : Nature and Source of — After- 
pains : Treatment of — The Lacteal Secretion : Milk Fever : Colostrum — The 
Child to be put to the Breast at Fixed Intervals — Agalactia — Galactorrhea : 
Two varieties of — Management of Lactation — Effects of Over-feeding — Dura- 
tion of Lactation — Effects of Menstruation and Pregnancy upon Lactation — 
Disorders of Lactation — Inflammation and Abscess of the Mamma : Effects of: 
Treatment — Excoriation and Fissure of the Nipples : Prevention of; Treat- 
ment of, . .607 

CHAPTER XXXIX. 

THE NEWLY BORN CHILD. 

Management of the Cord — Clothing — Cleanliness — Light and Air — Colostrum : Im- 
proper use of Laxatives — The Mother to Nurse if Possible — Selection of Hired 
Nurses; their Diet and Regimen — Causes of Difficulty in Sucking — Congenital 
Malformations — The Excretory Functions — Diarrhoea: Simpleor " Catarrhal," 
and Inflammatory or " Dysenteric " Varieties : Treatment of Each — Constipa- 
tion: Management of — Icterus Neonatorum — Thrush — Artificial Feeding: 



XV111 CONTENTS. 

Substitutes for Breast-Milk: Cow's Milk, Diluted and Sweetened: Nursing- 
Bottles: Nurse to be procured if Child does not Thrive: Other Articles of 
Diet ; Liebig's Food for Infants — Weaning — Dentition, . . . 626 

CHAPTER XL. 

PHLEGMASIA DOLEXS. 

The Puerperal State in its Relation to Disease — Phlegmasia Dolens : Nomen- 
clature — Causes ; after Labor and when Unconnected with Delivery — Symp- 
toms : Premonitory Signs : Pain : White Swelling : Tension : Heat : Constitu- 
tional Symptoms : The Limb Pits on Pressure during Convalescence : Loss of 
Power in the Limb — Morbid Anatomy: Character of the Effused Fluid : Plug- 
ging of the Veins ; State of the Lymphatics — Pathology: Milk-leg: Angeio- 
leucitis : Crural Phlebitis : Experiments of McKenzie and H. Lee : Views of 
Tilbury Fox : Review of the Pathology of the Subject — Treatment ; Is Blood- 
letting justifiable? Blisters: Bandaging: Is Contagion Possible? General 
Treatment to be directed as a rule to a Condition of Debility : Tonic Regimen : 
Antiseptic Remedies — Cause of Protracted Convalescence, . . . 642 

CHAPTER XLI. 

PUERPERAL INSANITY. 

Nomenclature — Normal Effect of Pregnancy on the Mind — Insanity associated 
with Pregnancy, Labor, or Lactation — True Puerperal Insanity : Pathological 
Theories : Connection of Puerperal Insanity with Albuminuria — Puerperal 
Mania: to be distinguished from Phrenitis : is essentially a Disease of Exhaus- 
tion — Symptoms: Significance of a Rapid Pulse : Violence: Delusions — Prog- 
nosis — Puerperal Melancholia : Distinguishing Characteristics : Probable Ter- 
minations — Treatment: Prevention: Bloodletting to be Avoided: Manage- 
ment of the Digestive Functions: Emetics: Vascular Sedatives: Nervous 
Sedatives; Opium, Hyoscyamus, Chloral, etc. : Diet and Regimen: Seclusion 
and Restraint: Treatment during Convalescence: Tendency to Recurrence 
after Subsequent Labors, 658 

CHAPTER XLII. 

PUERPERAL ECLAMPSIA. 

Definition — Connection between Eclampsia and Acute Bright's Disease — Eclampsia 
from other Morbid Conditions — Effects of Pregnancy on the System — Period 
of Explosion — Symptoms : Premonitory Signs ; (Edema, Albuminuria, Cephal- 
algia, etc. — Phenomena of the Fit: Period of Tonic and Clonic Convulsions, 
and of Coma — Pathology : Albuminuria : Decomposition of Urea, and Forma- 
tion in the Blood of Carbonate of Ammonia : Effects of Pressure on the Renal 
Veins : Detection of Albumen in the Urine — Morbid Anatomy — Effect of La- 
bor Pains — Maternal and Foetal Mortality — Prognosis: in Eclampsia Gravi- 
darum, Parturentium, et Puerperarum — Treatment: Prophylaxis: Use of 
Acids: Purgatives and Diuretics : Induction of Premature Labor : Treatment 
during the Fit: Bloodletting; Chloroform; Chloral: Obstetrical Treatment 
at Various Stages of Labor; Acceleration; Rupture of the Membranes ; Use 
of the Forceps, 672 



CONTENTS. XIX 



CHAPTER XLIII. 

PUERPERAL EEYER AND ALLIED AFFECTIONS. 

Perplexing Nature of the Subject — Puerperal Fever : Does a Specific Puerperal 
Poison really exist? — Should the term "Puerperal Fever" be retained? — 
Metria — Physiological Peculiarities of the Puerperal State — Puerperal Septi- 
caemia — Mode of Septic Poisoning — Connection with certain Zymotic Influ- 
ences; Erysipelas, Small-Pox, Scarlet Fever, etc. — Connection with Post- 
partum Inflammations — Puerperal Peritonitis ; May exist independently 
of Puerperal Fever: Symptoms of an Ordinary Attack; of the more Severe 
form — False Peritonitis — Puerperal Metritis ; of less Frequent Occur- 
rence : Symptoms — Uterine Phlebitis; Symptoms at first Obscure: Sec- 
ondary Abscesses in the Later Stage: Tissues chiefly involved — Vaginitis; 
Sthenic and Asthenic — Inflammation of the Uterine Lymphatics, . . 687 

CHAPTER XLIY. 

puerperal fever, etc. (Continued). 

Question of Contagion — Septicemic Infection — Other Specific Poisons — Are Inflam- 
matory Cases Contagious ? — History of Epidemics — Symptoms of Puerperal 
Fever — Morbid Anatomy : Malignant and other Varieties Contrasted : Lesions 
of other Organs : Pathological Appearances no Indication of the Virulence of 
the Attack — Evidence of a Change of Type in Puerperal Fevers — Treatment : 
All Varieties to be Treated as if Contagious : Recorded Results of Bloodletting 
and Purging: Gooch's Treatment: Connection of Metastatic Inflammation 
with Thrombus and Embolism : Uterine Phlebitis : Purulent Formations ; 
Effect of Emetics; Calomel and Opium; Turpentine; Blisters and External 
Applications; Tonic and Stimulant Treatment: Tapping the Peritoneum: 
Prophylactic Treatment : Cleanliness : Use of Antiseptics, . . . 701 

CHAPTER XLV. 

DIPHTHERIA OF PUERPERAL "WOUNDS. 

Prevalence during the past five years — Symptoms — Those which precede the out- 
break — Digestive System — Pain and Abdominal Tenderness — Pulse and Res- 
piration — Temperature — Countenance — Mental Condition — Local Symptoms — 
False Membrane on Wounds — Joint Complications — Diagnosis and Prognosis 
— Pathological Anatomy — Nature — Causes — Treatment: Quinia: Opium: 
Local Remedies : Cauterization of Diphtheritic Wounds : Vaginal and Intra- 
uterine Injections : Prophylaxis, ........ 719 

CHAPTER XLVI. 

PELVI-PERITONITIS : SUDDEN DEATH IN PUERPERAL PERIOD : ANAESTHESIA. 

Pelvi-Peritonitis — Inflammation of the Uterine Appendages— " Fulness," 
" Hardness," and " Tumor " — Pelvic Cellulitis : Anatomy of the Pelvic Cellu- 
lar Tissue — Bernutz on Pelvi-Peritonitis — Diagnosis of Pelvic Cellulitis and 
Pelvi-Peritonitis — Engorgement of the Uterus — Detection of Pus: Fluctuation 
— Treatment : Alleviation of Pain : Application of Leeches, Poultices, Fomen- 



XX CONTENTS. 

tations, etc. : Methods of Promoting Absorption ; Mercury; Iodine; Counter- 
irritation ; The Operative Treatment of Abscess — Peri-uterine Hematocele — 
Sudden" Death in Puerperal Period: Embolism of Pulmonary Artery — 
Arterial Embolism — Entrance of Air into Veins — Anaesthesia : Various 
Anaesthetic Agents : Effects of Chloroform on the Blood, and on the Progress 
of Labor : Disadvantages of Chloroform : Modern Practice, . . . 730 

APPENDIX, 745 

INDEX, 753 



LIST OF ILLUSTRATIONS. 



FIG. 

1. Pelvis of the female guinea-pis:, . ....... 

2. The same; showing the separation of the bones during parturition, 

3. Diagram showing the direction in which the uterine contents gravitate 

in the Mammalia generally, ........ 

4. Diagram showing the oscillatory movement referred to (Matthews 

Duncan), ........... 

5. External surface of right os innominatum, ..... 

6. Internal surface of the same bone, ....... 

7. Sacrum and coccyx — internal surface, ...... 

8. 9. Male and female pelves contrasted, as seen from before (Quain), . 
10, 11. Male and female pelves contrasted, as viewed in the axis of the brim 

(Quain), ............ 

12. Internal surface of female pelvis, showing — 1, 2, greater and lesser saero 

sciatic ligaments; 3, 4. greater and lesser gaps or foramina, 

13. Diagram showing the inclination and axis of the true pelvis, . 

14. Diagram showing the axis of the parturient canal, .... 

15. Interior of pelvis, showing the ischial planes, . . . . 

16. Outlet of the female pelvis, ........ 

17. Infantile pelvis, ........... 

18. External organs, partially dissected (Kobelt), ..... 

19. Showing the relative position of the pelvic organs, .... 

20. Dissection of the lower half of the female mamma during the period o 

lactation (Luschka), ......... 

21. Structure of a lobule of the mammary gland, ..... 

22. Ultimate glandular vesicles of the mamma, ..... 

23. Diagram showing relative position of the pelvic viscera (A. Farre), 

24. Profile section of the uterus, ........ 

25. Lateral section of the uterus, ........ 

26 The os uteri, ........... 

27. Pelvic organs in situ, viewed in the axis of the brim (after Schultze), 

28. Anterior view of the uterus and its appendages (Quain), . 

29. Posterior view of the uterus and its appendages (Quain), . 

30. Diagrammatic view of the uterus and its appendages as seen from behind 

(Quain), . 

31. Utricular glands of uterus (E. H. Weber), 

32. Utricular gland of the uterus (Coste), ...... 

33. Kelation of utricular glands to muscular tissue of uterus (Coste), 

34. Termination of utricular glands on mucous surface of uterus (Coste), 

35. Utricular orifices of uterus (Sharpey), ...... 

36. Double vagina and uterus (after Busch), ...... 

37. Bifid uterus, 

38. Diagram showing the layers of the Graafian vesicle, and the contained 

ovum, . 

39. Diagrammatic representation of the ovum, as it escapes from the Graafian 

vesicle, ............ 

40. Development of Graafian vesicles in the sow, ..... 

41. Ovary dissected, to show the structure of the Graafian vesicle at variou 

stages (Coste), 

42. Structure of the corpus luteum (Coste), ..... 

43. The corpus luteum of simple ovulation, ...... 

44. Corpus luteum in the third month of pregnancy (Montgomery), 



PAGE 

26 
26 

29 



32 
34 
35 

35 

37 

38 

40 
41 
42 
44 
45 
47 
51 
52 

56 
57 
57 
59 
60 
60 
61 
63 
63 
64 

66 
69 
69 
69 
70 
70 
74 
74 

77 

79 
79 

81 
82 
84 

84 



XX11 



LIST OF ILLUSTRATIONS. 



FIG. 

45. 
46. 
47. 

48. 
49, 
52. 
53. 
54. 
55. 
56. 
57. 
58. 
59. 
60. 
61. 
62. 
63. 
64. 
65. 
66. 
67. 
68. 
69. 
70. 
71. 
72. 
73. 
74. 
75. 
76. 
77. 
78. 
79. 
80. 
81. 
82. 
83. 
84. 
85. 
86. 



89. 

90. 

91. 

92. 

93. 

94. 

95. 

96. 

97. 

98. 

99. 
100. 
101. 
102 
103 
104 
105 
106 
107 
108 
109 



Corpus luteum in the sixth month of pregnancy (Montgomery 
Corpus luteum at the period of delivery, ..... 
Tumefaction of the uterine mucous membrane during menstruation (after 

Coste), 

Spermatozoa and vesicles of evolution, .... 

50, 51. Successive stages of the cleavage of the yolk, 
External surface of the ovum, showing the area germinativa 
Diagram showing the earliest formation of the embryo, . 
Diagram showing early stage of development, . 
Further development of the ovum, ..... 

Development in a more advanced stage, .... 

Completion of the amnion, and formation of the umbilical cord, 
Diagram showing Hunter's theory as to the formation of decidui 
Formation of decidua ; first stage;, ..... 

Formation of decidua completed, ..... 

Flap of decidua reflexa turned down, disclosing the ovum, 
Foetal surface of the placenta, ...... 

Maternal surface of the placenta, ..... 

Section of the placenta, ....... 

Foetal villi of the placenta, ...... 

Ultimate foetal villus, highly magnified, .... 

Ovum opened, and embryo partly dissected, . 

The same embryo, further dissected, .... 

Posterior view of branchial apparatus, etc., 

Posterior view of fcetal heart, ...... 

Dissection of an ovum in situ, about the fortieth day, 
Attitude of the foetus in utero, ...... 

Uterine cavity at the fifth month, ..... 

Upper surface of fcetal cranium, ..... 

Diameters of the fcetal cranium, ..... 

Circulatory apparatus in the foetus, ..... 

Diagram illustrating Groodsir's theory of foetal nutrition.. 
Fibre-cells of the unknpregnated and gravid uterus contrasted 
External muscular layer of uterus, ..... 

Internal muscular layer of uterus, ..... 

Degeneration of fibre-cells after delivery, 

Diagram showing development of uterine cavity (after Schultze) 

Areola, and secondary areola of pregnancy (seventh month), 

Cervix uteri (primiparse), twenty-fourth week, 

Cervix uteri (pluriparae), twenty-fourth week, . 

Cervix uteri (primiparse) thirtieth week, .... 

Cervix uteri (pluriparae), thirtieth week, .... 

Cervix uteri (primiparse), at full term, .... 

Cervix uteri (pluriparae), at full term, .... 

To calculate the duration of pregnancy (after Schultze), . 

Diagrammatic representation of partition in twin pregnancy (1st variety). 

Twin pregnancy (2d variet} 7 ), ...... 

Hydatidiform degeneration of ovum, .... 

Intra-uterine amputation and attempted reproduction, . 
Retroflexion of the womb about the 16th week (Schultze), 
Retroversion about the 12th week (Schultze), . . . 
Parturient canal completed by the obliteration of the os and 
Distension of the perineum (after Hunter), 
Alleged inversion of placenta in the third stage, 
Normal position of the placenta in the third stage, . 
Mode of digital examination, ...... 

Cranial planes as they engage in the brim, 

First cranial position, ....... 

Internal lateral surface of pelvis, ..... 

Lateral obliquity of the head advancing in the axis of the bri 

The head approaching the outlet. First position, . 

First position as seen from above (Schultze), . 

Diagrammatic representation of successive stages of the first position, 

Second cranial position, . . . . . . 



85 



LIST OF ILLUSTRATIONS, 



XX111 



position, 



del 



of th 



FIG. 

110. Second cranial position at the outlet, 

111. Third cranial position, 

112. Fronto-anterior termination of the third 

113. Fourth cranial position, 

114. Fourth cranial position at the outlet, 

115. Diagram showing successive stages of rotation and 

facial position, . 

116. First position of the breech, 

117. Birth of the breech, .... 

118. Birth of the shoulders, 

119. Arm displaced upwards, . 

120. Birth of the head 

121. Fourth position of the breech, . 

122. Artificial delivery of the head in breech 

123. Transverse presentation — Dorso-anterior 

124. Transverse presentation — Dorso-posterioi 

125. Spontaneous expulsion. First stage, 

126. Spontaneous expulsion. Second stage, 

127. Spontaneous expulsion. Third stage, 

128. Case of complicated presentation, 

129. Braun's repositorium, 

130. Cells of fatty and healthy decidua, . 

131. Placental forceps, .... 

132. Dr. Aveling's apparatus for transfusion, 

133. Partial inversion (after Matthews Dunca 

134. 135, 136. Successive stages of inversio ut 

137. Thomas's method of reducing chronic 

Thomas), 

138. Rachitic pelvis, 

139. Malacosteon pelvis, . . 

140. Isabel Redman's case, 

141. Obliquely distorted pelvis, 

142. Flattening of the sacrum, . 

143. Funnel-shaped pelvis, 

144. Exaggerated sacral curvature, . 

145. Pelvic exostosis, .... 

146. Baudelocque's calipers, and Coutouly's pi 

147. Lumley Earle's pelvimeter, 

148. Manual pelvimetry (Ramsbotham), . 

149. Sketch of Chamberlen's forceps (Rigby), 

150. Straight forceps for ordinary use, 

151. Davis's forceps, ..... 

152. Hodge's forceps, .... 

153. Wallace's forceps, .... 

154. Smith's forceps, .... 

155. Elliot's forceps, .... 

156. Robertson's forceps, .... 

157. Simpson's forceps, .... 

158. Introduction of the lower blade, 

159. Introduction of the upper blade, 

160. The forceps applied, .... 

161. Forceps for application at the brim, . 

162. Curve of abnormal promontory, 

163. Introduction of long pelvic-curved force] 
164 Diagram, showing various stages in the introduction of 

(lower blade), ....... 

165. Introduction of the first bl^de in the dorsal position 

166. Introduction of the second blade in the dorsal position 

167. Instruments introduced and locked in dorsal position, 

168. Long forceps applied, 

169. Ziegler's forceps, 

170. Radford's forceps, 

171. The vectis, .... 

172. Whalebone fillet, 



e uterus 



n th 



(after 



the long forceps 



first 



PAGE 

300 
304 
307 
308 
308 

318 
328 
329 
330 
331 
331 
333 
340 
344 
344 
347 
347 
348 
354 
364 
371 
384 
417 
419 
419 

429 
445 
446 
446 
447 
448 
448 
448 
451 
453 
455 
455 
462 
465 
466 
467 
468 
469 
470 
470 
471 
477 
478 
478 
483 
489 
491 

492 
493 
494 
495 
496 
498 
498 
501 
503 



XXIV 



LIST OF ILLUSTRATIONS. 



FIG. 

173. The blunt hook, 

174. The crotchet, .... 

175. Podalic version, 

176. Turning by the noose or fillet, . 

177. Malacosteon pelvis, . 

178. Bimanual version : first stage, . 

179. Bimanual version: second stage, 

180. Bimanual version : third stage, 

181. Simpson's perforator, 

182. Hodge's craniotomy forceps, 

183. Guarded crotchet, 

184. Craniotomy forceps, . 

185. Osteotomist, .... 
180. Meigs's craniotomy forceps, 

187. Braun's eranioclast, . 

188. Simpson's omphalotribe, 

189. French cephalotribe, 

190. Dr. Matthews Duncan's cephalotribe 

191. Hysterotomy, .... 
192 Barnes's uterine dilators, . 

193. Uterine polypus as an obstacle to delivery 

194. Ovarian tumor obstructing delivery, 

195. Double-headed monster, . 

196. Double monster, .... 

197. Head represented descending directly in the axis of the brim, 

198. Head represented descending in the position described by Naegele, 

199. Lateral obliquity of the head advancing in the axis of the brim, 



504 
505 
514 
517 
522 
524 
525 
525 
529 
530 
532 
533 
533 
535 
535 
539 
539 
539 
549 
568 
575 
576 
591 
591 
746 
746 
747 



A SYSTEM OF MIDWIFERY, 



CHAPTEE I. 



IKTRODTJCTOBY. 

HISTORY OF MIDWIFERY — HIPPOCRATIC ERA — ARABIAN SCHOOL — AMBROISE PARE - 
— MATJRICEAU — ENGLISH MIDWIFERY — OBJECTIONS TO THE PRACTICE OF MID- 
WIFERY CONSIDERED— COMPARATIVE ANATOMY OF THE PELVIS — THE PELVIS 
AS A TUBE THROUGH WHICH THE PRODUCT OF CONCEPTION PASSES — PARTU- 
RITION IN THE PRIMATES: IN THE VARIOUS RACES — THE ERECT POSTURE THE 
MAIN CAUSE OF COMPARATIVE DIFFICULTY IN THE HUMAN SPECIES — THE 
HUMAN PELVIS A CURVED CANAL — SEPARATION OF PELVIC ARTICULATIONS 
DURING LABOR — MIDWIFERY DEFINED. 

The History of Midwifery is to the student of that art a subject not 
only interesting, but also in some degree instructive. To trace from 
their earliest development, whether in the crude ideas of ancient times, 
or in the hasty generalizations of an epoch not far distant from our own, 
the growth and maturity of theories which we now believe to be in 
accordance with the truth, is indeed in itself an attractive pursuit ; and 
the student has his reward in the thorough mastery he thus obtains 
over details, which can scarcely be eifected by the mere dogmatism of 
ordinary teaching. 

For various and evident reasons, however, the history of the obstetric 
art cannot be embraced fittingly within the limits which must be fixed 
for matter purely introductory to the study of a great practical subject. 
Not even in outline, then, will a consecutive history of midwifery be 
attempted ; but, as reference will in the sequel be not unfrequently 
made to the doctrines and practice of the past, a few sentences may 
here be devoted to the consideration of the midwifery of certain epochs, 
in view of the influence which these may be supposed to exercise on the 
practice of the present day. 

From the earliest records, more or less authentic, which seem to throw 
light upon the subject, it would appear that the practice of midwifery 
was in the first ages entirely in the hands of women. If we may judge, 
however, from the fact that a law was passed in Athens, at a very early 
period, by which women were absolutely prohibited from practicing 

2 



18 INTRODUCTORY. [CHAP. 

physic in any of its branches, we are entitled to assume that the art 
had not in the main prospered in their hands. It is in the Hippocratic 
writings that we find the first trace of a profound intellect and a truly 
scientific mind being applied to the observation of the phenomena of 
parturition. The works, indeed, on this subject, which are attributed 
to Hippocrates, are, for the most part, passed over as unauthentic by 
modern critics ; but there can at least be no doubt that they were 
written before Aristotle, at the latest, we may assume, about 400 B. C. 
The head, according to this authority, is the only natural presentation ; 
and when the child either lies across or presents by the feet, the woman 
cannot be delivered. Observe the effect of this aphorism. The head 
being thus assumed to be the only presentation in which the natural 
forces could effect delivery, it follows, as the natural corollary of this 
proposition, that one of the chief aims of operative midwifery must be 
to convert breech and footling as well as transverse presentations into 
presentations of the head. The contemplation of such a state of prac- 
tice is too horrible to dwell upon. His graphic illustration of the 
olive in the neck of the oil jar is familiar to all, and demonstrates to 
perfection that it can, in its long diameter, be easily passed through; 
but, he adds, if the long diameter of this oval body be thrown across, 
either the bottle will break or the olive will be crushed. It is strange, 
indeed almost incredible, that, having recognized the form of the foetus 
while in the womb, as his simile clearly shows, he should have failed 
to perceive that an oval body, be it olive or foetus, may pass by either 
end of its long diameter. Overlooking this fact, he established a rule 
of practice, which obtained in after ages, as there is every reason to 
believe, for a period little short of 2000 years, at what expense of 
maternal and foetal life it is impossible to compute. From this early 
period we must also date the operation of Craniotomy, for the per- 
formance of which quite intelligible rules are given. 

This error of Hippocrates was corrected by Celsus in the first century 
of the Christian era, and even, to some extent, at a much earlier date 
by Aristotle; but it is to the former that the credit in this matter is 
usually ascribed by the commentators, as his words are clear and free 
from ambiguity. Tins is manifest from the following sentence alone, 
extracted from the instructions given by him for the management of 
transverse cases : " Medici vero proposition est, ut eum manu dirigat, 
vel in caput, vel etiam in j)edes y si forte aliter compositus est." 

Some four or five hundred years later, a careful compilation of all 
that had been written up to that time on the subject of midwifery was 
made by iEtius. Among the untoward circumstances detailed as 
causes of difficult labor, he mentions a narrow pelvis, the presence of 
polypi, and obliquity in the position of the womb. He states, further, 
that an anchylosis of the ossa pubis at their point of junction is a 
fertile cause of difficult labor, by preventing the separation which 
would otherwise, he supposes, occur; and that distension of the rectum 
or bladder may constitute a mechanical impediment to delivery. He 
observes also, that difficult labor is due as well to a faulty condition 
of the child as to the maternal parts. If the child, or any of its parts, 
were unduly large, labor was presumed to be impeded by the fact that 



I.] MIDWIFERY AMONG THE ANCIENTS. 19 

the motions and leaping of the ehild (supposed, even in comparatively 
modern times, to contribute greatly to its delivery) was thereby inter- 
fered with. Many other points of interest and of practical importance 
are referred to by him, one or two of which may be noticed. We have 
here, for example, in a chapter, " De Foetus Extractione ac Exsec- 
tione," which he takes from Philumenus, the first indication of the 
speculum vaginae, in an instrument which he recommends for the 
purpose of separating the external parts, in order to bring the cause of 
obstruction into view. We have also a perfect description of the 
crotchet (uncinus attractorius) ; and in his description of a method of 
delivery by the application of two crotchets — one to each side of the 
head — we cannot fail to observe that the mechanical principle of the 
midwifery forceps was not only then adopted in practice, but was 
thoroughly understood by the author, and brought him very near to 
the discovery of the forceps of modern times. And, finally, we have 
here the operation of turning in cases of difficult cranial presentation 
recommended, in terms which place it beyond a doubt that the pro- 
cedure indicated is in all respects identical with what of late years has 
been introduced in similar cases, as a novelty and an improvement in 
modern practice. The credit of the discovery and demonstration of 
the Fallopian tubes was claimed by Galen, but there is no doubt that 
they were described at a still earlier period than the epoch now in 
question by Rufus Ephesus, who lived in the reign of Trajan (circa 
A. D. 110). The last writer on this subject of the old Greek school was 
Paulus iEgineta, to whose works little originality can be attributed. 

The favor in which literature and the sciences were held by the 
Arabs evidently exercised a most beneficial influence in the development 
of the Arabian School of Midwifery. The name of Rhazes, a physician 
of Bagdad towards the end of the ninth century, is associated with the 
discovery of the fillet. About a hundred years later a very remarkable 
and voluminous series of works on midwifery and allied subjects was 
given to the world by Avicenna, a physician of Ispahan. His works 
consist for the most part in a confirmation of the leading views of the 
Greek school, and as they enjoyed an extraordinary popularity in 
Europe, as well as in Asia, it was by this channel mainly that the errors 
of the ancients were diffused throughout the world. The fundamental 
error of Hippocrates he adopts in a modified degree. All presentations, 
says he, save the head, are preternatural : the head ought, therefore, to 
be reduced, in all such cases, into the natural position, but, should this 
be impracticable, we may deliver by the feet. He recommends in 
certain cases the use of the fillet, which, when used for extraction, is 
to be fixed over the head ; and, should this fail, the forceps is to be 
applied to the head and extraction then attempted, while as a last 
resource only are the perforator and crotchet to be employed. 1 A 
reference to this passage makes it perfectly clear that the instrument 
alluded to is essentially the midwifery forceps ; while the fact that the 
author nowhere describes the instrument as a novelty warrants us in 

1 See the chapter, " De regimene ejus, cujus partus tit difficilis causa magnitudi- 
nis foetus." 



20 INTRODUCTORY. [CHAP. 

the belief that, about the tenth century, or possibly at an earlier period, 
the use of this important instrument was familiar to the Arabian 
physicians. In the works of a later writer, oi' the eleventh or twelfth 
century, 1 the forceps then used in midwifery is described and delineated. 
It is represented under two different forms, the misdach and the 
almisdaGh. In the Arab original in the Bodleian Library at Oxford 
to which Smellie refers in his learned introduction, the former of these 1 
is described as straight and the latter as curved, but in the Latin version 
both are described as circular and full of teeth. 

From this period, until the discovery oi' the art of printing in the 
middle of the fifteenth century diffused a knowledge of the writings of 
the ancients throughout the civilized world, our art seems to have made 
but little progress. Indeed, wo may even say with truth, that after 
the decline of learning in the East, the art of midwifery, as practiced in 
Europe, was far interior to what obtained among the Arabians and even 
among the later Grecian writers. This we may easily understand if 
we reflect that Hippocrates was the text-book in the hands of all, and 
that his errors continued to influence the practice of midwifery until 
the dawn of science, after the dark ages of our art, dissipated in some 
measure the mists of ignorance and superstition. 

In 1518, Dr. Linacre, physician to Henry VI 11, obtained, through 
his interest with Cardinal Wolsey, letters-patent constituting a corporate 
body of regular physicians in London. This foundation of the Royal 
College oi' Physicians of England marks the period at which midwifery, 
for tin 1 first time in this country, was brought within the domain of 
science. It must be confessed, however, that the earliest efforts of 
English authors contributed but little to the advancement of the art, as 
founded upon true scientific principles. The first English work on the 
subject was a translation ofEucharius Rodian, by \h\ ftaynalde, under 
the title of " The Byrthe of Mankynde." 2 That this work was held in 
no little repute on the Continent is evident from the fact that it had 
been translated from the original High Hutch, not only into Latin, but 
also into Hutch, French, Spanish, and other languages. Ami yet, when 
we examine it critically, we find that, except as a literary curiosity, it 
scarcely merits our attention. Not only does he indorse the famous 
blunder of Hippocrates, by saying that we should turn the child to the 
natural position even when the feel present, but he boldly promulgates 
another error when he says that when the child presents in the natural 
way by the head, the face and foreparts of the foetus are towards the 
foreparts of the mother. In most other respects his views are but 
copies from the ancient writers. The same remark may be made with 
reference to the productions of his contemporaries, as we find doctrines 
which are essentially the same promulgated in the collections of mono- 
graphs, memoirs, and reproductions from ancient and modern sources, 
known as the " Gynseciorum Commentaria," a collection familiar to all 
who have studied this subject with care. A very superficial study of 
this compilation will suffice to show that even the more flagrant errors 
of the ancients were still systematically taught; and therefore arc we 

1 Albueasis or Alsaharavius. 2 London, 15(55. 



I,] AMBROISE PARE. 21 

bound to conclude that the Hippocratie aphorism of turning, by the 
head in breech presentation had, up to this period, been all but univer- 
sally adopted in European practice, even although that error had been 
to a great extent corrected by the later Greek and the Arabian writers. 
It is not, then, too much to assert, as we have done, that the blunder of 
Hippocrates, so frequently alluded to, was the rule of practice for little 
less than 2000 years after his death. 

In this collection, however, there is one work which we must mention 
with more respect — that of the illustrious Ambroise Pare" — of whom 
Smellie says no more than is his due when he terms him "the famous 
restorer and improver of midwifery." The revival of anatomical study 
under Vesalius, and the numerous dissections which had been made of 
pregnant women by him and by his follower Columbus, had already 
corrected many of the anatomical and physiological errors, which, being 
time-honored, were therefore considered to be respectable, and were 
generally admitted to be true. The belief in these doctrines being thus 
sapped by the logic of facts, the whole rotten superstructure began to 
crumble away, and from this epoch modern midwifery may be said to 
have had its origin. It required a mind of no ordinary power and 
energy to be the pioneer in this new path ; but it requires no critical 
analysis of the work of Pare to show that the great surgeon was a 
great master, and that scientific Midwifery as well as Surgery had at 
last found a fitting modern exponent. Pare advises turning by the feet 
in difficult cranial presentations; but if this cannot be done, he recom- 
mends craniotomy, or delivering by the 4 crotchet, — which instrument he 
directs us to fix, by the method of JEtius, in the orbit or mouth, or below 
the chin. He frankly confesses, that although he has carefully studied 
the position of the foetus in utero, he has been unable to come to a 
satisfactory conclusion as to what is to be considered the normal posi- 
tion ; while, as regards the causes of difficult labor, he dilates at some 
length, and on the whole with considerable accuracy. After pointing 
out with great clearness the serious nature of the impediment caused 
by cicatrices, the result of former midwifery accidents, he enumerates 
the various positions of the foetus which interfere with or prevent 
delivery, and concludes by noting the bad effects of a premature escape 
of the waters, and of uterine inertia. 

At this period, the Parisian school was undoubtedly the first in the 
world; and as all the leading surgeons there practiced midwifery, the 
practice as well as the theory of obstetrics became rapidly developed. 
Guillemeau, surgeon to the French king, and a pupil of Ambroise Pair, 
further developed the theories of his master; but the book which seems 
to have exercised the greatest influence was the remarkable one of 
Mauriccau, " Sur les Maladies des Femmes grosses, et de ccux qui sont 
accouchees." This author gives by far the best account which, up to 
his day, had appeared of the phenomena of labor as observed by the 
accoucheur. He criticizes with some asperity the views of Columbus, 
which, however, we find to be, at least as regards the position of the 
child in the womb, infinitely more correct than his own. The following 
are his conclusions on this point: Up to the seventh or eighth month, 
the child is situated in the centre of the womb, the head being towards 



22 INTRODUCTOKY. [CHAP. 

the fundus and the face looking directly forwards. About this period 
an important change takes place in its position, which, if it happens 
sooner, is attended with danger. The weight of the head and upper 
part of the infant having now become relatively greater, it causes the 
child to turn forwards (/aire la culbute en devant), so that the face is 
now turned directly backwards to the promontory of the sacrum. This 
doctrine is simply an amplification of the views of Hippocrates on this 
point; and it must be admitted, even in the present day, that the 
greater relative frequency of breech and irregular presentations in cases 
of premature delivery, lends some apparent confirmation to the idea. 
He repudiates the idea formerly entertained, that the child, by its own 
instinctive or automatic movements, aided in any way in effecting its 
expulsion, and recognized not only the contractility of the uterine 
tissue, but also the supplementary expulsive force which is derived 
from the muscles of the abdominal walls, these acting, as he shows, 
with greater effect upon the rounded back and nates of the child than 
they could upon the head, did the head present. Mauriceau seems also 
to have some indistinct and inaccurate idea of the rotation which occurs 
in the pelvis; for, after stating that, in footling cases, it is necessary 
that the face in its descent should look backwards, he gives directions 
for turning the child during its descent, unless this has already taken 
place, so as to make the heels look directly forward. 

Any one who may wish to pursue this subject further will find 
ample and most interesting material in the works of Peu, Dionis, 
Deventer, La Motte, Puzos, Roederer, Levret, and others. In many 
of these, new errors are developed, such, for example, as the undue 
importance given to uterine obliquities by Deventer and his followers, 
who supposed them to be a frequent cause of tardy labor. The re- 
discovery of the midwifery forceps by the Chamberlens, about the 
middle of the seventeenth century, marks another and most important 
epoch ; but this will fall to be more particularly considered when we 
come to discuss the forceps and its uses. 

The interesting subject of the mechanism of parturition was inaugu- 
rated little more than a hundred years ago by Sir Fielding Ould, of 
Dublin, and this, too, is another important era in the history of mid- 
wifery. To trace the successive steps, from the faint glimmering of 
the truth which perplexed the shrewdness of Ould, and baffled the 
astuteness of Smellie, to the full development of the modern theory as 
it was laid before the scientific world in the celebrated essay of Naegele, 
would lead us upon ground which for the present we must avoid. In 
the sequel, and at the proper place, such of the historical facts as are 
essential to the comprehension of this subject will be briefly noted. 1 

It seems, on first sight, a paradox that the practice of midwifery 
should involve, in the human species, the supervision of a function 
which is purely physiological, and should be claimed by its professors 
as an important branch of the healing art. So difficult, indeed, has 
this problem been of solution, that many, from Rodericus a Castro 

1 For a critical analysis of this subject, see an essay by the author " On the 
Mechanism of Parturition." London, 18G4. 



I.] OBJECTIONS TO THE PRACTICE OF MIDWIFERY. 23 

downwards, have asserted that the practice of the art was derogatory to 
professional dignity, and an unnecessary interference with a natural 
process. " Obstetriciam artem nee exercui nee exercere volo," wrote 
one of these ; and there is reason to believe that the words find an echo 
even now. We need scarcely pause to refute the former of the two 
objections. We presume we may hold it as proved that, from the very 
earliest times, women required and obtained assistance at the period of 
delivery. This assistance was afforded, as we have already seen, by 
persons of their own sex ; and that there is a fitness in this no one will 
gainsay. If we may judge, however, from the Athenian laws, we may 
assume that the practice of obstetrics did not prosper in the hands of 
women ; but it must be confessed that there is evidence enough in the 
works of Arsinoe and Cleopatra to prove that some of them, at least, 
were quite familiar with the doctrines and practice of their age. And 
it must be conceded further, in these days when women are knocking 
so loudly, and with such importunity, at the portals of professional 
recognition, that if the mantle of Mesdames La Chapelle and Boivin 
could be made to fall on the shoulders of their sisters of the present 
generation, female delicacy would be saved many a rude shock, and the 
cause of science would in no sense suffer. But what do they say who 
repudiate the general practice of the art? Women, they assert, should 
in their hour of need be attended by women, and only in the case of 
difficulty or danger should the male accoucheur be summoned. The 
answer to this simply is, that the assistance of the latter would, under 
such cireu instances, be of no value whatever, as without a knowledge 
of the healthy or normal standard, which can only be attained by the 
constant observation of the natural process, ignorance, not skill, would 
be called upon to act. To the full as rational would it be to ask him 
to compute distance or space who had no knowledge of the standards 
of lineal measurement or capacity. Certainly, in the present day, Men 
are required for the practice of midwifery, skilled in medicine and the 
applied sciences, and who do not think of their dignity, any more than 
of their ease and comfort, when their services are in this matter required. 

In regard to the other objection, we must, of course, admit that 
parturition is a physiological function. But, in the discharge of this 
function, there exist in the human species peculiar conditions which 
exercise, as compared with the lower animals, a special influence upon 
the progress and issue of labor. What these conditions are will be 
best understood by a reference to one or two points in comparative 
anatomy, which reveal certain analogies, the appreciation of which 
will clear away many difficulties, and a knowledge of which is, in 
point of fact, almost essential to the student of midwifery. 

At an early period of mammalian development, two rods or bars of 
cartilage may be observed passing, more or less obliquely, from the 
dorsal towards the ventral surface of the embryo near its caudal ex- 
tremity. 1 The two parts are separated at their dorsal extremity, where 
they embrace the vertebral column ; while in front, in most cases, they 
meet and form a symphysis. This is the primitive pelvis. As the 

1 See Flower's " Osteology of the Mammalia." London, 1870. 



24: INTRODUCTORY. [CHAP. 

process of development goes on, the cartilage of each side, widening to 
a great extent superiorly, ossifies from three centres, by the union of 
which the os innominatum is formed, the two lower segments — ischium 
and pubis — leaving a gap between them, the obturator or thyroid fora- 
men. If we except the Cetacea and Sirenia, in which the pelvis is 
almost rudimentary, these characteristics are common to the whole 
mammalia. The innominate bones are firmly united above to the 
sacral vertebra?, and usually below to each other at the symphysis ; and 
this union, firm as it is, is greatly strengthened by a double ligament- 
ous union of considerable strength between the sacral and caudal ver- 
tebra? on the one hand, and the ischia on the other. This is familiar 
to anatomists as the greater and lesser sacro-sciatic ligaments, which 
are sometimes replaced by bone — as in the sloth. 

The mammalian pelvis, then, by the union of the two innominate 
bones and the sacrum, forms, with some exceptions, a complete circle 
or girdle of bone; or, in other words, a short canal or tube, which has 
two outlets. Of these, the anterior is called the inlet or brim, which is 
marked more or less distinctly by a line which runs from the top of 
the symphysis pubis to the first sacral vertebra. The axis of this is — 
owing chiefly to the obliquity of the innominate bones — probably 
never parallel to the vertebral column, but diverges from it, more or 
less widely, according to what is termed the " inclination" of the brim. 
The outlet looks backwards or downwards according to the position of 
the animal, and is bounded in the dorso-ventral diameter by the caudal 
vertebra? on the one side, and the lower margin of the pubic symphysis 
on the other, and laterally by the great sacro-sciatic ligaments (or bones) 
and the converging borders of the ischia. As the planes of brim and 
outlet are never quite parallel, the axis of the pelvis is consequently 
more or less of a curve. 

A careful study of the form, and extent of development, in the 
various mammalian groups, shows clearly that, as in other parts of the 
skeleton, the ever-watchful provision by nature of means to an end is 
here strikingly exemplified. In the Cetacea, where there are no pelvic 
limbs, the pelvis is composed of two slender bones ununited inferiorly, 
the chief use of which seems to be to afford an attachment for the crura 
of the penis and clitoris. In the Armadillo, it is strong and powerful, 
to aid in the support of the exo-skeleton. In the Carnivora, the ilium 
and ischium are in a straight line and of nearly equal length, the pelvis 
being thus elongated and narrow. The symphysis is long, includes 
part of both pubis and ischium, and, in adult animals of this class, is 
usually closed by anchylosis. In the Seals, the pelvis is small and of 
a different form from the terrestrial Carnivora, the ilia being small, 
and the ischia and pubes long and slender. The symphysis is small 
and loose, admitting of being widely separated during parturition. 

In many of the Insectivora, the symphysis is absent, the bones being 
widely separated in the middle line. The pelvis of the mole, for 
example, is long and narrow, and its axis is nearly parallel with the 
vertebral column. The ischium, as well as the ilium, is united to the 
sacrum by anchylosis, and the brim is so narrow that, there being no 
union at the symphysis, the pelvic viscera lie external to the cavity, 



I.] COMPARATIVE ANATOMY OF PELVIS. 25 

and parturition takes place beneath rather than through the pelvic canal. 
In the Rodentia the pubes and ischia are always largely developed, flat 
and diverging posteriorly, while the symphysis is long and usually 
osseous. The Guinea-pig is an exception, as here the union remains 
ligamentous, and admits of free opening during labor. 

In the order Ungulata, the Pecora or true ruminants are character- 
ized chiefly by the great development of the ischial tuberosity, forming 
a well-marked conical process which is diverted outwards on each side. 
The symphysis is long, and includes a considerable portion of the ischia, 
and large epiphyses are observed, forming the articulating surfaces. 
These parts ultimately become fused by anchylosis. In the Perisso- 
dactyla, the greater expansion of the ilia, as seen in a marked degree in 
the skeleton of the elephant, indicates, at first sight, an approach to the 
human type; but the narrowing of the pelvis at the level of the acetab- 
ula, and the comparatively small ischial and pubic portions, at once 
dispel the illusion. 

The Edentata have the pelvis more or less elongated, and the ischia 
largely developed. In almost all, the ischia are directly connected 
with the vertebral column by one or more osseous bridges, the single 
one in the sloth passing from the ischial spine, and thus representing 
the lesser sacro-sciatic ligament. This is carried to the greatest extent 
in the Armadillos, where a long unyielding tube is formed by the 
coalescence of the ilium and ischium on the one hand, and a consider- 
able number of sacral and pseudo-sacral vertebras on the other. In 
most of the Edentates, not only the sacro-iliac articulations, but also 
the symphysis pubis, are anchylosed. 

The Marsupiata and Monotremata are characterized by the great 
development of the ischia and pubes, and the development in the tendon 
of the external oblique muscle of the " marsupial" bones. 

The facts here cited will suffice to show that the pelvis, in the various 
groups into which the mammalia have been divided, is formed so as to 
suit the requirements of the individual. The mode of locomotion, be 
it leaping, running, or swimming, is revealed to the anatomist by an 
examination of the pelvic bones, and in every case it will be seen that 
the preponderance of ilium, ischium, or pubis, is due to the necessity 
which exists for certain mechanical arrangements, by which alone can 
the required muscular power be effectively applied to the bony levers. 
The pelvis is also an efficient support to the organs which are usually 
contained within it, and especially to those which are connected with 
the function of generation. 

The obstetrician, however, looks at the pelvis from a different point 
of view. In it he sees the osseous canal through which the product 
of conception must pass in the act of parturition. He sees in it also 
the protecting framework which shields the generative viscera from 
the effects of shock or injury. And, above all, he studies it as a structure 
which, if abnormal, may seriously obstruct the process of parturition. 
Let us look, then, for a moment, before quitting the subject, and from 
this standpoint, at the pelvis of the mammalia. Throughout the whole 
series, irrefragable evidence is afforded that the pelvis is' designed with 
a direct reference to the propagation of the species; and we find more- 



26 



INTRODUCTORY, 



[chap. 




Fig. 1. — Pelvis of the female guinea-pig. 
Fig. 2.— The same ; showing the separation of the 
bones during parturition. 



over, that, on the approach of labor, certain modifications of structure 
which then occur clearly prove that nature prepares the parts before- 
hand for the new function. Thus, in the Chevrotains, a group of little 

deerlike animals, formerly as- 
sociated with the musk-deer, 
the ischia in the males join the 
elongated sacrum by ossi fi ca- 

o ... 

tion of the sacro-sciatic liga- 
ments, but in the females the 
latter retain their normal ex- 
tensile texture. In the prolific 
guinea-pig, again, 1 the pelvis is 
long and laterally compressed, 
the passage being much nar- 
rower than the diameter of the 
head of the mature foetus. 
About three weeks before par- 
turition, the interpubic liga- 
ments become soft and extensile, 
sothatduring labor the innomi- 
nate bones separate from each 
other at the symphysis, the 
sacro-iliac joint thus becoming on each side a hinge. After this process, 
the symphysis quickly returns to its normal or former state, and in a 
few days presents only a little thickness and mobility. The young of 
the guinea-pig are far advanced at birth ; some of the deciduous teeth 
are shed in utero, and they run about and begin to eat soon after they 
see the light. 

In the cow, as the period of parturition approaches, a relaxation of 
the pelvic ligaments also occurs, but the process here is different. 2 The 
gradual upward curve and posterior projection of the ischia causes the 
well-marked dorsal projection of their tuberosities, which appear promi- 
nently on the rump, projecting on each side and above the coccygeal 
vertebra?. By this elevation of the ischia, the sacro-sciatic ligaments 
become a means of support to the pelvis, so that their action is, as 
compared with the corresponding structure in the human pelvis, as it 
were inverted. As the period of utero-gestation approaches its termina- 
tion, these ligaments, as well as those of the sacro-iliac joint, become 
relaxed to such an extent that the sacrum is observed to sink down- 
wards between the innominate bones, so that the ischial tuberosities 
become very prominent, and relatively elevated. The object of this is 
manifestly to render parturition easier. Did this, indeed, not occur, 
there can be little doubt that in the cow, as in some other ruminants, 
the difficulties of labor which occasionally arise would be of much more 
frequent occurrence. It is interesting to observe, as the probable cause 
of dystochia in those animals, that, owing to the greater curve of the 



1 Owen. 

2 Todd'* 
Pelvis. 



" Comparative Anatomy and Physiology of the Vertebrates." 
Cyclopaedia of Anatomy and Physiology." Supplement. 1859 



Art. 



I.] COMPARATIVE ANATOMY OF PELVIS. 27 

sacrum, the axis of the pelvis is necessarily more strongly curved than 
usual, and in this respect approximates to the human type. 

If we now turn to the Primates, we shall be able to show, by a com- 
parison of the human race with those of the mammalia which stand 
nearest to it in the scale, that the process of childbirth must be more 
difficult and more obnoxious to serious hindrance than in any — even 
the highest — of the other mammalia. In all the Simiina, the ilium is, 
as compared with man, much elongated. " Each os innominatum in 
the adult male gorilla," says Owen, " is one foot three inches in length, 
that of man being seven inches and a half; the breadth of the ilium 
is eight inches and a half, that of man being six inches." In the 
lower forms — as the baboons and monkeys — the ilium is even longer, 
relatively to the other bones of the pelvis, than is here described. The 
ilia are nearly in a straight line with the vertebral column, and the 
inferior rami of the ischia are directed almost horizontally inwards, 
entering into the formation of the pubic symphysis, which, in the 
ape tribe generally, may be more properly called the ischio-pubic sym- 
physis. The form of the cranium is the familiar and ready test, not 
only in distinguishing between man and the lower animals, but also 
between the various races of mankind. It is peculiarly interesting to 
us, however, to observe that a careful examination of the pelvis will 
also supply the same and as reliable information. The chief peculiari- 
ties of structure which are exhibited in the case of the highest of the 
Simiina have just been noticed. In addition, we observe that the 
depth both of the true and false pelvis is much greater than in the 
human race, that the sacrum is much narrower, especially in the chim- 
panzee, that the ischial spines are more closely approximated, and, 
above all, the antero-posterior measurements at the brim prevail greatly 
over the transverse. 

Were we to compare the highest Ape with the lowest Man, we would 
find the following broad points of distinction. In the Ape, a pelvis 
with the brim much more inclined, its antero-posterior exceeding its 
transverse measurement ; a bending of the pelvic brim at the ilio- 
pectineal eminence forming an angle of about 120°, called the Mo-pubic 
angle — a characteristic which, without exception, distinguishes the 
lower animals possessing pelves ; a marked elongation of the ilia ; and 
a parallelism of the symphysis with the vertebral axis. In Man, less 
inclination of the brim, and a constant preponderance of the transverse 
over the antero-posterior diameter ; the boundaries of the brim here 
alone in the animal kingdom on one plane ; great expansion of the ilia, 
as compared with their length ; and the symphysis forming an angle 
with the vertebral column. The import of this great gap in develop- 
ment is evident, and has its explanation in the adaptation of man alone 
of all created beings to the fully erect posture. 

The descriptive anatomy of the human pelvis will form the subject 
of another chapter. We shall here glance only at its special functions, 
in so far as they may be held to differ from those of the lower animals. 
In all the other mammals the habitual and only natural position or pos- 
ture of the animal is prone, — the dorsal surface being superior, the ventral 
inferior. In those in which pelvic limbs exist, the weight of the pos- 



28 INTRODUCTORY. [CHAP. 

terior or pelvic portion of the trunk alone is transmitted through the 
pelvis to the cotyloid cavities, and thence transferred to the heads of 
the thigh-bones. In Man, the whole weight of the body above the 
pelvis is directly transmitted to it by the imposition of the last lumbar 
vertebra, on the base of the sacrum, from which again it is transferred, 
when the body is erect, to the femora, and in the sitting position, to the 
tuberosities of the ischia. To enter upon an analysis of the mechanical 
laws upon which this depends would be suitable to a work on animal 
physics, but we must here confine ourselves to such points only as are 
germain to our subject. 

The sacrum — which is relatively much broader and stronger in man 
than in any of the lower animals — is the part which receives the weight 
of the trunk, the centre of gravity being, according to Weber, 8.7 milli- 
metres above the sacro-lumbar joint, or just above the pelvic arch. It 
has been compared by Cruveilhier to a wedge, by others to the key- 
stone of an arch, and by Sir Charles Bell to the heel of a mast, — the 
base of the vertebral column being fixed so that the interval between 
the innominate bones may be looked upon as the step in which the 
vertebral mast is socketed and mortised. In any case we may consider 
the weight as being transmitted from the sacro-iliac joints in one of 
two directions: in the erect posture, it passes through the irregular, 
thick, and curved buttresses which are formed by this portion of the 
ilia directly to the cotyloid cavities; in the sitting posture it passes, on 
a posterior plane, from the same joints almost directly downwards to the 
tuberosities of the ischia. The sacrum is thus described as forming the 
common culminating point of two arches — viz., the cotylo-saeral or 
standing arch, and the ischio-sacral or sitting arch. The extremities of 
these arches are prevented from starting outwards, not by abutments as 
in the ordinary architectural arch, but by connecting links or ties, which 
are represented in the cotylo-saeral arch by the horizontal rami of the 
pubes, and in the ischio-sacral by the united isehio-pubic rami. This 
complicated arch acts also by preventing inward pressure, in the erect 
posture, by the head of the femur; while shock is in a great measure 
obviated by the oblique manner in which the sacrum is placed — the 
sacro-sciatic ligaments preventing the movements of the coccyx upwards 
and backwards, while the ilio-lumbar ligaments prevent the correspond- 
ing motion of the base of the sacrum downwards and forwards. 1 The 
expanded external surfaces of the ilia give attachment to the mass of 
the glutei muscles, more powerful, for obvious reasons, in man than in 
any other animal. 

But the pelvis has, in addition to the elaborate mechanical functions 
above shortly alluded to, a new and special function thrown upon it in 
Man. This is the support of the pelvic viscera, including the organs 
of generation. These latter being larger and heavier in the female, 
and, in view also, no doubt, of the requirements of the pregnant state, 
nature here makes special provision for their accommodation, in the 
greater capacity and modified form to which we shall afterwards advert. 

1 Dr. Matthews Duncan, in bis " Researches on Obstetrics'' (p. 55), shows more 
correctly, that the weight is transferred from the sacrum to the cotyloid cavity, not 
directly, hut indirectly through the agency ot the posterior ilio sacral ligaments. 



I-] 



COMPARATIVE ANATOMY OF PELVIS, 



29 



Fig. 3. 




Diagram showing the direction 
in which the uterine contents grav- 
itate in the Mammalia generally. 



In the lower animals, the abdominal viscera, and, to some extent, also, 
the pelvic viscera, are supported by the lower abdominal wall. The 
contents of the pregnant uterus, therefore, gravitate downwards in the 
direction of the arrow in the figure, and, under no circumstances, does 
the weight of the uterine contents press into 
the cavity of the pelvis. Even in the 
Simiina, where the erect posture is to some 
extent assumed, the greater inclination of 
the pelvic brim prevents the gravitation of 
the uterus and its contents into the true 
pelvis. In a pregnant woman, on the other 
hand, not only are the pelvic viscera proper 
supported by the structures which form the 
floor of the pelvis, but some support is indi- 
rectly afforded to the abdominal viscera 
under certain circumstances. In the preg- 
nant state, the uterus and its contents gravi- 
tate to a considerable extent downwards 
and backwards in the axis of the brim. 

The necessity which thus exists for efficient 
pelvic support to these parts has not been 

overlooked. Were the pelvis a simple tube, with the inlet looking 
upwards, and the outlet downwards, it is obvious that no efficient sup- 
port could be afforded. But the tube, far from being straight, is in a 
woman strongly curved — so strongly indeed, that a line drawn so as 
to represent the axis of the brim and the long axis of the uterus (which 
we may here assume to be identical) will not fall within the plane of 
the outlet at all, but behind it, somewhere about the centre of the 
coccyx. By this curve in the pelvic axis, the lower part of the sacrum, 
the coccyx, the sacro-sciatic ligaments, the levatores ani and coccygei 
muscles, and the fascial and soft structures form a firm floor, by which, 
in a normal and healthy condition of the parts, perfect support is given 
to the structures of which we have spoken. But this manifest advan- 
tage is obtained at the price of increased difficulty in the act of parturi- 
tion. This difficulty is, no doubt, to a very great extent, compensated 
for by the development of the subpubic arch, a peculiarity of the 
human species which is but imperfectly developed in the lower animals. 
Without this, indeed, and that shortness of the symphysis in women 
which admits of its widest development, labor would be always diffi- 
cult and often impossible. 

The function of the pelvis being thus in every case a complicated 
one, is so in the human female in an especial degree. The unyielding 
nature of the structure, essential to the effectual support of the trunk, 
and the curving of its cavity for the reasons above stated-, render child- 
bearing in this instance exceptionably liable to dangers of various kinds, 
and thence arises the necessity for that thorough training which can 
alone engender confidence and develop skill. 

The comparative facility with which parturition is effected in the 
lower races of the human species has also been used as an argument 
against the practice of midwifery. In reference to this objection, on 



30 INTRODUCTORY. [CHAP. 

which we need not dwell, there can be little doubt that the effect, in 
certain classes of society, of modern and luxurious habits, exercises no 
inconsiderable influence upon the physiological phenomena of parturi- 
tion. As regards the difference between the races, many very interest- 
ing facts have been revealed by the researches of Vrolik, Weber, and 
others, but there is still in this direction a wide field for original 
investigation. The facts which already have been disclosed point to 
the important conclusion that there subsists in the various races a 
remarkable coincidence between the prevailing form of the skull and 
the diameters of the pelvic brim, and that, consequently, the adaptation 
of the foetal skull to the pelvic passage during labor must be greatly 
facilitated. Weber's conclusions, drawn from the observation and 
measurements of a considerable number of specimens, are, that we may 
admit, as the general rule, subject however to numerous exceptions, that 
the oval shape is most common in Europeans, the round shape in the 
American aborigines, the square shape in the Asiatic or Mongolian type, 
and the oblong in the Negro races. As regards the assumed facility of 
labor in those races, there is every reason to believe that this has been 
greatly exaggerated, and that cases of dystochia, though comparatively 
rare, are yet not unfrequent. If the pelvis were the same in size and 
proportion in them as in Europeans, the inferior cranial development 
would afford an obvious explanation of the alleged fact of habitually 
easy labors. So far, however, from this being the case, we have just 
seen that the form of the pelvis corresponds to the shape of the head. 
An examination of Negro, Bushman, and other pelves, shows in many 
instances a remarkable degradation of type, such as a vertical direction 
of the ilia, and their elevation at the posterior-superior spines, narrow- 
ness of the sacrum, and acuteness of the subpubic angle. An occa- 
sional peculiarity in some of the lower races, and one which appears 
even more to approach to the ape type, is the preponderance of the con- 
jugate over the transverse diameter of the brim. But they who have 
asserted that the lower races referred to simulate in this respect apes 
rather than Europeans have gone too far, as is clearly proved by the 
measurements given in Wood's admirable article on the Pelvis in Todd's 
Cyclopaedia, already quoted. From this it appears, that while the 
transverse may, in the higher Simiina, measure less than the conjugate 
diameter by one and a half to two inches, the difference in cases of 
oblong pelvis in negroes is merely fractional, and that the type is in 
every case far more closely allied to the European than to the Simian, 
where the conformation of the pelvis is such, even in the highest forms, 
that its marked peculiarities are appreciated at a glance. 

Whether the pelvic articulations in women are, or are not, divaricable 
during parturition, is a question obviously of great practical importance 
to the accoucheur. Involving, indeed, as it does, practical considera- 
tions, this is a subject, the study of which might here be considered 
premature. But, in view of the facts which have just been stated in 
relation to the comparative anatomy of the pelvis, this vexed question 
may, we believe, be noticed with more advantage at this stage than at 
any other. In so far as a study of the physiological phenomena of 
labor in the lower animals can throw light upon the subject, we have 



I.] MOBILITY OF PELVIC ARTICULATIONS. 31 

already seen that separation may take place to a very considerable 
extent at the symphysis, as in the guinea-pig, or at the sacroiliac joint, 
as in the cow. So far, then, analogy points to the possibility of such a 
separation. Besides, anchylosis of either one joint or the other, com- 
mon as it is in the lower animals, is known to be, in the human species, 
an extremely rare occurrence. 

Actual observation, again, by men of such undoubted authority, 
among many others, as Par6, Levret, and Smellie, has proved, beyond 
all possibility of doubt, that in women who have died during the par- 
turient period, separation of the bones, now at the symphysis and again 
at the sacro-iliac joints, has been seen and recorded. Few practitioners 
of extended experience have failed to observe that women occasionally 
complain, it may be either before or after labor, of pain in the neigh- 
borhood of these joints, difficulty or inconvenience in walking, and, 
more rarely, a grating or crepitant feeling, arising obviously from an 
unwonted motion of the articulating surfaces upon each other; from 
which we may conclude that separation may, to some extent at least, 
occur. Cases such as have been detailed by Soemmerring — where the 
bones at the sacro-iliac joint have been found separated to the extent of 
an inch — have been supposed to be the result of disease and deposit of pus. 

Admitting, then, that some separation does occasionally occur, are 
we to assume that this is to be held as morbid or abnormal, or admitted 
as one of the essential physiological phenomena of human parturition ? 
It is, we suppose, now universally believed that, during the last months 
of pregnancy, the cartilaginous and other structures forming these joints, 
to be hereafter described, become softened, as if by serous infiltration. 
The synovial membranes, indistinct before, now become capable of 
demonstration; and, more important, perhaps, than all, the tissues 
become thickened, while the ligaments of the joints are relaxed. The 
effect of such thickening must, of necessity, be, like ivy roots in a wall, 
to force the bones asunder and, consequently, to increase the pelvic 
diameters. If, however, there is, as has been asserted, a yielding much 
more extensive than this, such motion may be assumed to occur in one 
of two ways; either by a separation of the pubes, involving a hinge 
motion at the sacro-iliac joint, as in guinea-pigs, or by a movement of 
the sacrum between the ossa innominata, involving a hinge motion of 
the symphysis, as in the cow. As regards the first of these, a careful 
examination of the circumstances under which it may occur, would 
seem to indicate that a separation of the pubic bones to the extent even 
of an inch would add very little to the diameters of the brim, and 
would contribute least of all to the smallest or conjugate diameter. 
The analogy which the frequent yielding of the symphysis seems to 
reveal, gave rise, about the end of the last century, to an operation 
consisting in the artificial section of the symphysis in cases of obstruc- 
tion at the brim — a mode of procedure which Dr. Matthews Duncan 
seems to think has been in these days too completely consigned to 
oblivion. 

The other method in which the pelvic capacity may be increased by 
a movement of these joints, is by the motion of the sacrum between 
the ossa innominata, somewhat as it has been shown to occur in the 



32 



INTRODUCTORY. 



[CHAP. 



cow. 1 From what has already been said, it may be inferred, that to 
compare the sacrum either to a wedge or a keystone is very far from 
accurate. We have seen that this bone, besides its union with the 
sacrum by means of intervening cartilage, is maintained in its position 
by the ilio-lumbar and sacro-sciatic ligaments — the former preventing, 
or rather strictly limiting, along with other forces, the downward and 
forward movement of the promontory ; while the latter limits, in like 
manner, the upward and backward motion of the coccyx. Now, these 
ligaments share in the general relaxation of the pelvic structures towards 
the end of gestation ; and thereby we may assume, that the movement 
or oscillation on its transverse axis, of which the sacrum is capable, and 
which is said by Zaglas to be about a line in the unimpregnated con- 
dition, is, in the last months of pregnancy, considerably increased. The 
manner in which this oscillation of the sacrum takes place in different 
positions of the woman is clearly shown by Zaglas. " In the erect 
position, the promontory of the sacrum is not in the position of greatest 
projection into the brim of the pelvis, but the reverse; and, conse- 
quently, the apex is in its forward 
fig. 4. position, diminishing the outlet and 

relaxing the sacro-sciatic ligaments. 
When the body is bent forward, on 
the other hand, the base of the sac- 
rum is protruded into the brim, the 
apex is tilted upwards, the sacro- 
sciatic ligaments put on the stretch, 
and the outlet of the pelvis conse- 
quently enlarged. These move- 
ments take place, ordinarily, both 
in man and woman, in defecation, 
etc., but in her they are of greatest 
interest and importance in the func- 
tion of parturition. 7 ' 2 The backward 
motion of the coccyx has also the 
effect of producing lateral widening 
of the pelvis, by bringing a wider part of the base of the sacrum between 
the ilia. This, of course, supposes some gliding motion in the sacro- 
iliac articulation, or, at least, yielding of the parts. The experiments 
of MM. Giraud and Ansiaux seem to show that, in contracted pelves, 
the movements take place to an even greater extent, as if nature were 
doing her utmost to obviate the disastrous effects of pelvic deformity. 
Dr. Matthews Duncan, in his admirable essay on this subject, points 
out, with great clearness, the very remarkable manner in which these 
alterations correspond with the phenomena of the progress of the child 
in parturition. In the first stage of labor, for example, when the head 
is passing through the brim, the woman prefers the standing, sitting, 
or reclining posture, in which the brim of the pelvis is, as we have 
seen, kept open at the expense of the outlet (see Fig. 4) ; but in the 
second stage she bends her body forwards, draws up her legs, and calls 

1 Barlow. Monthlj* Journal of Medical Science, January, 1854 

2 Matthews Duncan. Op. cit, p. 142. 




Diagram showing the oscillatory movement 
referred to. (Matthews Duncan.) 



II.] THE PELVIS. 33 

into action the abdominal muscles, which act by tilting up the sym- 
physis ; in a word, her posture and voluntary efforts are now precisely 
those which may most effectively increase the conjugate diameter of 
the outlet by tilting back the coccyx. To the motion of the sacro- 
coccygeal joint, which is universally admitted, we need not at present 
specially advert. 

From these and other facts disclosed up to the present time we con- 
clude: 1st. That, in the last months of pregnancy, a marked relaxa- 
tion and softening of the pelvic articulations takes place. 

2d. That, as the result of this modification in structure, an in- 
creased, though limited, mobility is permitted, which tends to facilitate 
labor. 

3d. That in addition to the movement of the sacrum on its transverse 
axis, as above noted (and which may be considered as peculiar to the 
human species), the manner in which the joints yield is probably very 
similar to what obtains in the case of the cow. The sacrum acts in 
this case as a wedge separating the ossa innominata and causing the 
symphysis to open with a hinge motion, while, during the violent efforts 
of labor, the whole sacrum may probably be driven backwards to a 
trifling extent. Separation of the bones at the symphysis is occasionally 
observed, but this is probably the exception, while the other is the rule. 
The development of the synovial membranes seems, when taken along 
with the above facts, to warrant the conclusion arrived at by Lenoir, 
" that the articulations of the pelvis proper should not be considered 
as amphiarthroses, but as arthroses" 

The word " Midwifery," it is proper here to state, is employed in 
this work in the more extended sense in which it is used by Rigby and 
other English authors, and not in the limited sense which is implied 
by the French accouchement, and the German Geburtshiilfe. It signifies, 
therefore, that Science and Art, which has for its object the manage- 
ment of woman and her offspring during Pregnancy, Labor, and the 
Puerperal State. 



CHAPTER II. 

THE PELVIS. 

OS INNOMINATUM : SACRUM: COCCYX — THE PELVIS AS A WHOLE: "TRUE 7 ' AND 
"FALSE" — DIFFERENCE BETWEEN MALE AND FEMALE PELVIS: AT BRIM; 

IN cavity; and at outlet — PELVIC articulations: (a) PELVI-LUMBAR ; 

(b) SACRO-COCCYGEAL ; (c) SACRO-ILIAC ; (d) SYMPHYSIS PUBIS ; (e) OBTURATOR 
LIGAMENTS; (/) SACRO-SCIATIC LIGAMENTS — INCLINATION OF PELVIS — AXIS 
OF THE TRUE PELVIS — BRIM OR INLET — CAVITY — OUTLET— PEL VTC DIAM- 
ETERS — PELVIC ANGLES DEVELOPMENT OF PELVIS CERTAIN SOFT PARTS 

CONNECTED WITH PELVIS; OBTURATOR INTERNUS AND PYRIFORMIS MUSCLES; 
" FLOOR " OF PELVIS. 

The Pelvis, as has already been observed, is composed in Man, as 
in almost all the other Mammalia, of three parts : 1st, an os innomina- 

3 



34 



THE PELVIS. 



[CHAP. 



Fig. 5. 




External surface of right os innominatum. 



turn, formed by the union of three principal pieces, the ilium, ischium, 
and pubis, and some other epiphysial parts, the complete fusion of 
which into one mass is only complete about the twentieth year ; 2d, 
the sacrum ; and 3d, the coccyx. 

The Os Innominatum on its external 
surface exhibits the remarkable ex- 
pansion of the ilium which constitutes 
one of the distinguishing features of 
the human race. This large surface 
serves to give attachment to the pow- 
erful glutei muscles. Its superior 
margin is called the crest of the ilium ; 
the projections at 1 and 2 the ante- 
rior, and those at 3 and 4 the poste- 
rior spinous processes. The acetabu- 
lum, a deep cavity for the reception of 
the thigh-bone, also called the coty- 
loid cavity, with its synovial depres- 
sion and pit for the reception of the 
round ligament, is shown in the cen- 
tre of the figure. 5 marks the pecti- 
neal or ilio-pectineal eminence, a point 
of some importance in midwifery; and 
the other parts indicated are, 6, the 
symphysis pubis ; 7, the tuberosity of the ischium ; 8, the thyroid or 
obturator foramen ; and 9, the spine of the ischium, which divides the 
great posterior gap into the greater and lesser sciatic notches. 

In the view of the internal surface of the innominate bone, the figures 
1 to 9 indicate the same parts as in the preceding cut ; 10 is the iliac 
fossa ; 11, the ilio-pectineal line or brim of the true pelvis ; 12, auricu- 
lar cartilaginous surface of the sacro-iliac joint; 13, rough tubercu- 
lated surface for the posterior sacro-iliac ligaments ; 14, spinous process 
of the pubis, terminating the crest of the pubis and the ilio-pectineal line. 
The relative position of the rami of the ischium and pubis, and other 
points familiar to the anatomist, are clearly shown in both figures. 

The Sacrum is an irregular wedge-shaped or triangular bone, formed 
by the fusion of five vertebra?, and is more or less curved, with the con- 
cavity forwards, the base of the triangle being upwards. It is placed 
below the last lumbar vertebra, above the coccyx, and between the ossa 
innominata, and forms the upper and back part of the pelvis. It is in 
man stronger, and relatively larger, than in any other animal, this 
characteristic being specially marked in the female. The external or 
posterior surface is convex and rough, and there are four, and some- 
times five, processes placed below each other in the median line, repre- 
senting the spines of the original vertebra?. On either side, four 
foramina are observed, through which the posterior sacral nerves pass 
from the cauda equina, which is contained in a longitudinal canal, the 
continuation of that of the vertebral column. Below the last spinous 
process, is a triangular opening, which is the termination of the verte- 
bral canal, and of which the lateral margins terminate in a pair of 



II.] 



BONES OF PELVIS, 



35 



tubercles. These, which project downwards, and articulate with the 
cornua of the coccyx, are known as the sacral cornua. A row of tuber- 
cles is seen on the inside, and another on the outside of the foramina, — 
corresponding to the articulating and transverse processes of the 
vertebrae. 

The pelvic or anterior surface (Fig. 7) is concave from above down- 
wards, and slightly so from side to side, and is much smoother than 
the posterior. Four foramina, larger than those above described, are 




Fig. 7. 




Internal suiface of the same bone. 



Sacrum and coccyx — internal surface. 



provided for the transit of the anterior sacral nerves ; and between the 
foramina are four ridges, indicating the boundaries of the original 
vertebral constituents of the bone. 

Laterally, there is presented anteriorly an uneven surface of consider- 
able size, covered in the recent state with cartilage, and corresponding 
to the iliac articulating surface shown at 12, Fig. 6. This is called 
from its shape the auricular surface ; and behind it there is an extremely 
rough and uneven surface for the attachment of the posterior sacro-iliac 
ligaments. Below and behind this, the irregular surface gives attach- 
ment to the sacro-sciatic ligaments. 

The oval surface of the sacrum, which, looking upwards and for- 
wards, represents the base of the bone, is articulated, through the 
medium of the interarticular disk, with the last lumbar vertebra; 
while its narrow inferior extremity, transversely oval, is jointed with 
the superior surface of the coccyx. 

The Coccyx , the rudiment of the caudal vertebrae, generally consists 
of four small vertebral pieces tapering downwards to a point. It 
derives its name from a fancied resemblance to a cuckoo's beak, and is 
placed so as to continue, anteriorly and posteriorly, the curve of the 
sacrum. An oval surface (covered with cartilage and furnished with a 
synovial membrane) articulates with the apex of the sacrum ; and this 
union is strengthened by two small processes which project upwards to- 



36 THE PELVIS. [CHAP. 

meet the cornua of the sacrum. Not only is the sacro-coccygeal joint 
a perfect hinge, but the various bones of which the coccyx is composed 
also admit of some motion in early life the one upon the other. In 
adult life these bones are generally anchylosed, and the sacro-coccygeal 
joint is, in males generally, and in females occasionally, lost, so that 
the sacrum and coccyx are firmly joined together. 

The superior mobility of the coccyx in women is universally admit- 
ted as an important mechanical advantage in the process of parturition, 
the aiitero-posterior diameter of the outlet being by this resiliency 
increased, under ordinary circumstances, by an inch or even more. 
Usually, during the childbearing period, the parts are in the condition 
of complete mobility as regards the sacro-coccygeal joint, and yielding 
also between the first and second bone of the coccyx, while the last 
three bones are united. 1 In this respect, however, great irregularities 
exist, and sometimes, even in women who are still young, complete 
anchylosis is observed. The result of this is, of course, a very consid- 
erable impediment to delivery, and many cases are recorded where, 
during the use of instruments, or even in the course of ordinary labor, 
a fracture of the bones thus anchylosed has occurred. Premature fusion 
of this articulation, and malformation of the coccyx are conditions by 
no means very uncommon. The usual form assumed in the latter case 
is projection forwards, encroaching upon the conjugate diameter of the 
outlet; but a projection of the coccyx backwards has also been noticed 
by the writer and others, a condition which is interesting as an ana- 
tomical peculiarity, but is rather favorable than obstructive to the 
course of natural labor. In cases of fracture, care must be taken, dur- 
ing the reparative process, to prevent union in such a position as to 
constitute a possible impediment to delivery in subsequent labors. 

The Pelvis as a Whole. — The Pelvis is thus formed by the union of 
several pieces, the articulations or points of junction being, in front, 
the symphysis pubis, and, behind, the sacro-iliac and sacro-eoccygeal 
joints. These articulations are greatly strengthened by certain liga- 
mentous structures which will be presently described. 

It is divided into two parts by a line, the various parts of which are 
in man alone on the same plane. This, known as the ilio-pectineal line, 
marking the brim or inlet of the pelvis, runs on each side from the 
symphysis pubis outwards, upwards, and inwards, forming an irregu- 
larly oval constriction of the osseous canal. Various points in the 
course of this line, which divides the superior or false from the inferior 
or true pelvis, are of special interest to the obstetrician. In the middle 
line anteriorly is the symphysis pubis. Diverging right and left from 
this point, are the pubic crests, terminating in the pubic spines. The 
finger, on being passed around, next touches the pectineal or ilio-pec- 
tineal eminence, then the ilio-sacral articulation, and finally the pro- 
jection known as the promontory of the sacrum. This last point is of 
paramount importance, as the degree of projection which forms the 

1 Cazcaux assorts that the sacro-coccygeal articulation ossifies generally before 
the first and second bones become united. If this is correct, the mobility in these 
cases must manifestly be impaired. 



II.] 



MALE AND FEMALE PELVIS CONTRASTED. 



37 



Fig 



promontory exercises a most important influence on the progress of a 
case of labor. 

The true pelvis, then, includes the whole of that part of the structure 
which is below the brim as far as the outlet, the space comprised be- 
tween the two being the cavity. Each of these parts requires careful 
and separate consideration ; but, before passing to this part of the sub- 
ject, it is advisable that the striking contrast between the male and 
female pelvis, having an obvious relation to the function of parturition, 
should be noticed. 

The female differs from the male pelvis, in the first place, by the 
comparative slenderness of the bones, as is well seen in the rami of the 
ischium and pubis, and also by the greater smoothness of the surfaces 
to which muscles are attached. The chief points of distinction, as 
viewed from before, are 
well shown in Figs. 8 
and 9, in both of which 
the numbers 1 and 2 
represent the extremi- 
ties of the widest trans- 
verse diameter of the 
upper or false pelvis ; 
3 and 4 are the acetab- 
ula, right and left ; 5, 
5, the thyroid or obtu- 
rator foramina ; and 6, 
the subpubic angle or 
arch. The differences 
exhibited are those 
which exist between 
an ordinary male and 
female pelvis in mid- 
dle age : in neither case 
is there anything ex- 
aggerated or unusual. 
The greater distance in 
Fig. 9 between the ace- 
tabula, the wider and 
shallower true pelvis, 
the triangular form of 
the obturator foramen, 
the greater width be- 
tween the tuberosities 
of the ischia, and the 
greater span of the 
subpubic arch, are the 
chief points which at a glance show it to be a female pelvis. The last- 
mentioned point of distinction is very characteristic in well-formed 
pelves, the angle in males being no more than 75° to 80°, while in the 
female it reaches from 90° to 100°. 

Viewed from above and in front, at right angles to the brim of the 




Male and female pelves contrasted, 



(Quain.) 



38 



THE PELVIS. 



[CHAP. 



Fig. 10. 




Fig. 11. 



true pelvis, the contrast is scarcely less marked. In the lower of the 
two figures showing this view, the further peculiarities of the female 
pelvis are evidenced by the greater expansion of the ilia, the minor 

degree of projection of 
the promontory of the 
sacrum, and the mark- 
ed general increase in 
the diameters. In the 
cavity, the most note- 
worthy feature of the 
female pelvis is the 
diminution in the per- 
pendicular depth, the 
symphysis being in the 
male nearly double the 
depth, while the sac- 
rum is shorter as well 
as broader, and placed 
so as to offer a more 
ample concavity. It 
will also be noticed, 
in looking downwards 
and backwards, as is 
shown in Figs. 10 and 
11, that three projec- 
tions are seen — poste- 
riorly the sacrum and 
coccyx, and on either 
side the converging 
ischial planes, culmi- 
nating in the ischial 
spines. These projec- 
tions, encroaching, as 
they manifestly do, on 
certain measurements of the lower parts of the pelvis, have, as will be 
explained afterwards, a very important bearing upon the mechanical 
laws which govern the process of parturition. 

If, again, we look at the bony outlet, we find here also three projec- 
tions, posteriorly the sacrum and coccyx, and at the sides the ischial 
tuberosities. Between the latter is the subpubic angle, while between 
them and the sacrum on each side is the irregular sacro-sciatic gap, 
partly closed, as we shall see presently, by powerful ligamentous struc- 
tures, and much more spacious in the female than in the male. 1 These, 
the main features which enable us to distinguish between the male and 

i The greater expansion of the ilia, and divergence of the cotyloid cavities, give 
the chief peculiarities to the female figure, in regard to which the ancient Greek 
sculptors are probably not far from the truth in representing their ideal of female 
beauty as measuring a third more across the hips than the shoulders, while these 
measurements are reversed in the case of Apollo. The same peculiarity occasions 
the peculiar swinging gait, which is the more marked in a woman the broader the 
pelvis is in proportion to her height. 




Male and female pelves contrasted, as viewed in the axis of the 
brim. (Quain.) 



II.] PELVIC ARTICULATIONS. 39 

female pelvis, having now been noticed, we shall advert in future to 
the female pelvis alone. 

The ligaments and articulations which bind the various parts of the 
pelvis together may now be briefly noticed. 

a. Pelvi-lumbar Articulation. — In addition to the intervertebral disk, 
and the ligaments which are strictly analogous to those existing between 
the vertebras above, attention must here be paid to the sacro-vertebral 
and ilio-lumbar ligaments. The former passes, expanding as it descends, 
obliquely from the tip of the transverse process of the last lumbar ver- 
tebra, to the depressed lateral part of the base of the sacrum ; the latter 
horizontally between the tip of the transverse process of the last lumbar 
vertebra and the posterior margin of the iliac fossa, where it somewhat 
expands. 

b. Sacvo- coccygeal Articulation. — An anterior and posterior ligament, 
and an intervertebral disk, are here found as in the more perfect verte- 
bras. There is observed besides in women, and in a lesser degree in 
the male sex, a synovial membrane, described by Cruveilhier, and 
which converts this into a perfect hinge joint, the structure and mobility 
of which become, as has already been mentioned, much more obvious 
in the latter stage of pregnancy. 

c. Sacro-iliac Articulation. — The bones are here joined by a twofold 
union ; in the first place, by the cartilaginous auricular surfaces which 
are seen anteriorly when the parts are forced asunder, and from which 
the name synchondrosis is often given to the joint. Generally, these 
surfaces are closely united ; but in pregnant women, and, probably, 
under certain other circumstances, an indistinct synovial cavity may be 
demonstrated, admitting, as there is every reason to believe, of a certain 
amount of motion. This union is greatly strengthened by the posterior 
sacro-iliac ligaments, consisting of strong irregular bands of fibres which 
pass from the overhanging portion of the ilium to the contiguous rugged 
projections on the lateral surface of the sacrum. One of these bands, 
extending downwards from the posterior superior iliac spine to the 
third or fourth piece of the sacrum, in a direction different from the 
other fibres, is known under the name of the oblique sacro-iliac liga- 
ment. An anterior sacro-iliac ligament is also described, but is of 
little anatomical importance. 

d. The Symphysis Pubis. — This joint is, like the previous one, also 
effected by fibro-cartilaginous plates and ligaments. The two cartilages 
are thicker in front where they come into contact with each other, and 
thinner posteriorly, so as to leave a space which is, as in the other 
joints just described, lined by a synovial membrane. During preg- 
nancy, an effect is produced upon this joint precisely similar to what 
has been stated to occur in the sacro-iliac joints, but it is in this case 
even more marked. The articulation is materially strengthened by 
the ligaments which surround it, named respectively posterior, superior, 
anterior, and inferior pubic ligaments. Of these, the posterior is a layer 
of fibres of little strength ; the superior is connected with a band of 
fibres which arises from the spine of the pubis, and conceals the irregu- 
larities of the crest of the same bone ; the anterior is a layer of irregular 
fibres passing across from one side to the other, and crossing obliquely 



40 



THE PELVIS. 



[CHAP. 



Fig. 12. 



the corresponding fibres from the other side, and the inferior, triangu- 
lar, or subpubic ligament is so thick, and so formed by its attachments 
to the rami of the pubic bones as to give smoothness and roundness to 
the subpubic angle, and thereby to facilitate the passage of the foetus. 
e. The Obturator Ligaments. — These structures, which are more cor- 
rectly described as membranes, close almost entirely the obturator 
foramina, giving attachment externally and internally to the obturator 
muscles, and leaving only a small aperture in its upper and outer part, 
which serves to transmit the obturator vessels and nerve. 

/. Sacro-sciatic Ligaments. — These are two in number, longer in the 
female than in the male, and become, to some extent, relaxed during 
labor. The posterior, or great sacro-sciatic ligament (Fig. 12, 1), 

which is placed in the inferior and 
posterior part of the pelvis, is broad 
and triangular in shape, and extends 
from the inner surface of the ischial 
tuberosity, which is the apex of the 
triangle, to the side of the coccyx 
and sacrum, as far as the posterior 
inferior spine of the ilium. This 
extensive attachment constitutes the 
base. The fibres of the apex expand, 
so as to send a falciform process up- 
wards and forwards, along the margin 
of the ischial ramus, to join the fibres 
of the obturator fascia. 2 is the ante- 
rior or small sacro-sciatic ligament, 
which is both shorter and thinner 
than the other, and is also of a some- 
what triangular shape. Its fibres are 
directed forwards and outwards ; the 
fibres constituting its base are blended 
with those of the larger ligament ; and 
its apex is attached to the spine of the 
ischium. By means of these struc- 
tures, which are ossified in some of the lower animals, it will be observed 
that the sacro-sciatic notches are converted into foramina, great and 
small sacro-sciatic ; 3 and 4. Through the former of these, the pyri- 
form muscle, the great sciatic nerve, and the ischiatic vessels and nerves 
pass, while the latter admits of the exit from the pelvis of the obturator 
interims muscle and the pubic vessels and nerve. 

The obstetrician may look upon these ligaments as discharging a 
double function. They act, as has already been mentioned, by pre- 
venting the displacement of the apex of the sacrum upwards and back- 
wards, — an accident wdiich, without their aid, the very oblique position 
of that bone would in the erect posture be likely to engender; and 
therefore, in this sense, they strengthen the sacro-iliac articulation. 
But, in addition to this, they close in, in some measure, the large 
irregular opening which constitutes the outlet of the pelvis ; forming, 
at the same time, the framework of those soft structures which consti- 




Internal surface of female pelvis, showing 
— 1, 2, greater and lesser sacro-seiatic liga- 
ments; 3, 4, greater and lesser gaps or for- 
amina. 



II.] 



INCLINATION OF THE PELVIS. 



41 



Fig. 13. 



tute the floor of the pelvis — which exercise a very important influence 
on the progress of labor, and which act also by affording an efficient 
and elastic support to organs which would otherwise be liable to fre- 
quent displacement downwards. 

In addition to the ligaments above described, there are others, some of 
them — as those of the hip-joint — of great importance; but as they have 
no special obstetrical interest, their description may here well be omitted. 

Inclination of the Pelvis. — If we place the articulated pelvis on a 
table, so as to bring the tip of the coccyx and the ischial tuberosities 
into the same horizontal plane, the brim of the pelvis will be found to 
look upwards and slightly forwards. This was at one time supposed 
to be the actual position in the erect posture ; and many persons now 
living may remember to have seen articulated skeletons in which the 
pelvis was so placed. Hence the term "horizontal," which use and 
wont has attached to the upper of the two rami of the pubis. JNaegele 
was the first clearly to show, not only that this was an error, but that 
it was a very gross one, 1 and that the pelvis was, in the normal position, 
inclined forwards to such an extent that the plane of the brim met the 
horizon at an angle of 60° or more (Fig. 13, a). The same observer, 
after examining a large num- 
ber of well-formed female 
bodies, concluded, further, 
that the average height of 
the promontory of the sacrum 
above the upper margin of 
the symphysis pubis is about 
3} inches, and that a line 
drawn from the tip of the 
coccyx to the lowest part 
of the symphysis, formed 
with the horizon at b an 
angle which varies greatly, 
but which may be stated, as 
an average, at about 11°. 
In reference to this, however, 
it must be borne in mind, 
that the recession of the 
coccyx implies a movement 
downwards as well as back- 
wards, and that, conse- 
quently, this angle will be 
rendered still more acute 
during the passage of the child. The axis of the brim of the pelvis, 
then, is a line, c d, which passes upwards and strongly forwards, while 
that of the bony outlet is directed downwards and slightly backwards. 
The axis of the cavity is usually described as the perpendicular of a 
line drawn from the middle of the symphysis pubis to the centre of the 
sacro-coccygeal curve. 




\« 



Diagram showing the inclination and axis of the 
true pelvis. 



Das Weibliche Becken," etc. Carlsruhe. 1825. 



42 



THE PELVIS. 



[CHAP. 



Fig. 14. 



Axis of the True Pelvis. — If the bony pelvis were a simple cylinder, 
the demonstration of its axis would be a very simple matter. All that 
would then be necessary would be to make a section, perpendicular to 
its walls, when the axis of the cavity would be shown to be a line inter- 
secting the plane represented by this section, and equidistant from every 
part of the cylinder wall. The same simplicity of description will not, 
however, suffice in the case of the irregular and curved pelvic cylinder. 
What is known as the "curve of Carus" was at one time generally 
supposed to represent the axis of the pelvis. This curve is described 
in the following manner: The compasses are opened to the extent of 
2J inches : one point is placed upon the central point of the posterior 
surface of the symphysis, while with the other a curve is drawn from 
the plane of the brim to the plane of the outlet, the segment of the 
circle thus indicated being assumed to represent the axis of the pelvis. 
A mere superficial observation of the human pelvis will serve to show 
that neither this nor the segment of any circle can truly, or even ap- 
proximately, represent the axis in question. 

Although not absolutely free from technical objection, we may assume 

that the following more modern view 
brings us much nearer the truth : If 
we produce the lines in the above dia- 
gram, which represent the planes of 
the brim and outlet, to their point of 
intersection in front of the symphysis 
at o, and from this common centre 
draw an infinite number of radii pass- 
ing through the pelvic cavity ; each 
of these radii may be held to represent 
the plane of that portion of the cavity 
through which it passes. If we then 
draw a line which shall pass through 
the geometrical centre of each of these 
planes, that line will be found to be a 
curve, which coincides very closely 
with the axis of the true pelvis, which 
is the segment of no circle, and which 
has been described as an irregular para- 
bola. One point must here, however, 
be noted — that as the terminal planes 
or radii will be modified by the motion 
of the coccyx during labor, so in like 
manner will the inferior portion of the 
curve be proportionally altered. This 
is indicated in the diagram, where the 
line cf marks the parabolic curve or 
assumed true pelvic axis. 

We must here be careful in drawing 
a distinction between the axis of the 
outlet of the bony pelvis, and that axis which represents the direction 
in which the child is born. In considering the latter, it is essential 




Diagram showing the axis of the 
parturient canal. 



II.] INTERIOR OF PELVIS. 43 

that the soft parts forming the floor of the pelvis should be looked upon 
as constituting the posterior and inferior boundary of a continuation 
of the pelvic canal. These parts, which extend from the tip of the 
coccyx to the posterior commissure of the vagina, are subjected during 
delivery to an amount of stretching for which nature makes due pro- 
vision. The sphincter of the anus is dragged asunder, the perineum 
distends in all directions in a manner apparently incompatible with the 
integrity of that structure, until ultimately, at the moment of expulsion, 
the fourchette is driven downwards and carried forwards to such an 
extent, that a line drawn from the subpubic angle to the edge of the 
distended perineum, shows the plane of the outlet of the completed 
pelvic canal to look, not downwards, but almost directly forwards (Fig. 
14, a b). The line e, perpendicular to, and meeting the centre of this 
plane, is then the axis of expulsion. The tendency of that part of the 
child which is first born is to move upwards and forwards under the 
pubic arch, and in front of the symphysis, in continuation of the curve 
indicated in the diagram by dotted lines. 

Let us now look more closely at the various parts of this tube which 
attract special notice, viz., the Brim, the Cavity, and the Outlet. The 
Brim presents (Fig. 11, p. 38) an irregular oval appearance, the long 
diameter of the oval being from side to side. It has been found on an 
average to measure in the antero-posterior or conjugate diameter, ap, 
which is taken from the promontory of the sacrum to the upper edge 
of the symphysis pubis, 4 J inches. Its greatest transverse measure- 
ment, 1 1, is 5J inches. In addition to these, there is also described an 
oblique diameter, extending from the sacro-iliac synchondrosis on each 
side to a point near the ilio-pectineal eminence on the other. This 
measures 5 inches, and it must be remembered that these diameters 
take their name "right" (r o), or "left" (I o), oblique according to the 
sacro-iliac synchondrosis from which they spring. 1 

It will thus be observed that, in the skeleton, the transverse is the 
longest diameter of the three, but, when the soft parts are in situ, this 
is not the case, as the iliacus muscle overlaps the brim, so as to 
diminish the transverse while it scarcely encroaches upon the oblique 
diameter. The effect of this is that the oblique is practically the longest 
diameter, a fact which we find of great interest and importance when 
we study the relation of the diameters to the foetal head. 

The Cavity of the pelvis is the whole tube between the brim and the 
outlet. As a general rule, the deeper the cavity the more difficult is 
the labor, for in this case the pelvis approximates in its formation to 
the male type. If the diameters are proportionally enlarged, labor 
may be, it is true, quite easy; but the rule undoubtedly is that, in the 
case of the tall handsome woman with dignified gait and carriage, the 
probability of a difficult labor is much greater than in the short, wide- 



1 In regard to this there unfortunately exists some discrepancy. The diameters 
are named right and left, as in the text, by the best English and German writers, 
but some eminent French and American authors have named them from the coty- 
loid cavity, thus inverting the meaning of the terms. 



44 



THE PELVIS, 



[CHAP. 



Fig. 15. 




Interior of pelvis, showing the ischial planes. 



hipped woman, in whom the swinging, or (to put it less gallantly) the 

waddling motion of her sex is more 
obvious. The cavity, as a single 
glance will show (Fig. 16), is deep 
posteriorly and shallow anteriorly. 
The average depth of the symphysis 
pubis gives the anterior depth at 1 J 
inches. The height of the planes of 
the ischia which corresponds to the 
middle depth may be stated as about 
3J inches. The depth posteriorly 
may be set down, if we measure 
directly from the promontory of the 
sacrum to the tip of the coccyx, as 
4J inches, which, if we follow the 
curve of the sacrum, will be in- 
creased to about 5 J inches, the former 
of these measurements making no 
allowance, however, for the yielding 
of the coccyx. Three diameters are 
also taken in the case of the cavity 
as representing its width : the conju- 
gate, from the centre of the symphysis pubis to the upper margin of 
the third sacral vertebra, 5J inches ; the transverse, from a point cor- 
responding to the lower margin of the acetabulum on one side to the 
corresponding point on the other, 5 inches ; and the oblique, from the 
centre of the great sacro-sciatic foramen on one side to the foramen 
ovale on the other, 5J inches. 

Looking now at the internal surface of the pelvic canal in a section 
such as is here shown, we may observe that the lateral wall is divided 
into two parts by a not very obvious line of demarcation (a b) leading 
downwards and backwards, from the ilio-pectineal eminence to the 
spine of the ischium. That part of the ischium which is in front of 
this looks slightly forwards, that which is behind slightly backwards. 
These are the anterior and posterior inclined planes of the ischium, sup- 
posed by Desormeaux, Tyler Smith, and many others, to determine 
the rotation of the head in the mechanism of parturition. To this, 
however, we shall return. 

While the brim or inlet of the pelvis is directed, as we have seen, 
upwards and forwards in the erect posture, that of the outlet, owing to 
the curve formed by the axis of the cavity, looks backwards, and, when 
the coccyx is extended, almost directly downwards. 

The conjugate diameter of the outlet (Fig. 16) extends from the 
lower margin of the symphysis pubis to the tip of the coccyx, and may 
be set down as 5 inches. In many cases the measurement is much less 
than this, and in any case the diameter may be increased to the extent 
of an inch or even more by the mobility of the coccyx during labor. 
The transverse, from one tuber ischii to the other, is about 4| inches ; 
and the oblique, from the middle of the lower edge of the great sacro- 



II.] 



PELVIC DIAMETERS. 



45 



sciatic ligament on one side to the point of union between the ischium 
and pubis on the other, also 4f inches. 

The facts which are brought out by those figures are chiefly these : 
(a) That the transverse measurement of the pelvic tube becomes pro- 
gressively diminished from above downwards, being greatest at the 
brim and smallest at the outlet. This is due, as a single glance down- 
wards in the axis of the brim 
will show, to the gradual 
approximation of the ischia 
(Fig. 11). (6) That the con- 
j ugate diameter is, on the con- 
trary, increased from above 
downwards, in consequence 
of the recession or curve of 
the sacrum, progressively 
from brim to outlet, if we 
allow for the bending back 
of the coccyx. These facts, 
which are associated with a 
remarkable rotation which 
the child undergoes during 
labor, are moreclearly shown 
when, as in the following table, the figures above noted are brought 
into juxtaposition. Along with these, a few of the more important of 
the many measurements which have been made of the female pelvis 
are also set down in inches, according to the average of the most recent 
and approved observations. 




Outlet of the female pelvis. 



MEASUREMENTS OF THE FEMALE PELVIS. 

1. Circumferential measurement of the brim, 

2. Between widest part of iliac crests, .... 

3. " Anterior superior spines of ilium, 

4. " Front of symphysis and sacral spines, 



True Pelvis. 
Brim, . 
Cavity, 
Outlet, 



Conjugate. Transverse. 

. o-i- 5 

. 5 2 4| 



17 

10| 

10i 

7 

Oblique. 
5 

[4|] 



All the measurements given in this table are, it must be remembered, 
those of the skeleton — no allowance being in any case made for the 
soft parts ; and to them we may add another measurement, which has 
an important bearing on practical considerations arising from the study 
of a certain class of pelvic deformities. This is the sacro-cotyloid 
diameter, which is about 3 J inches in a well-formed pelvis, and is rep- 
resented by a line drawn from the centre of the sacral promontory to 
the region above the cotyloid cavity. The encroachment of the psoas 
and iliacus muscles, with investing and other structures, reduces the 



1 The oblique diameters of the cavity and outlet are placed in brackets, as, not 
being taken from fixed bony points, they are of comparatively little importance. 

2 When coccyx forced back. 



46 THE PELVIS. [CHAP. 

transverse diameter of the brim by about half an inch, while the other 
diameters of the brim, as well as of the cavity and outlet, are only 
reduced by an eighth to a quarter of an inch at the most. The oblique 
diameters are least of all affected ; but, owing to the presence of the 
rectum on the left side, the left oblique diameter is slightly shorter 
than the right. These facts have to be borne in mind in the course of 
examinations which are made with a view of estimating the capacity 
of the pelvis in its various parts, — a question often of vital import in 
the practice of midwifery ; and in such investigations it is also useful 
to know that the distance from the lower edge of the symphysis to the 
promontory of the sacrum is about half an inch more than the conju- 
gate of the brim. In regard to the measurements numbered 2, 3, and 
4 in the table, if these are to be estimated by measurements in the 
living body, from two to three inches must be added for the tegumen- 
tary and other external structures. 

In addition to the angles which have already been described as formed 
with the horizon by the planes of the brim and outlet, and measuring 
respectively 60° and 11° (Fig. 13), and the subpubic angle, there are 
several others which should not be overlooked. The sacro-vertebral 
angle is that which the sacrum forms with the upper portion of the 
vertebral column, and is estimated as 117° in the male, and 130° in 
the female. This remarkable contrast serves to show that there is no 
gain whatever in capacity by a sudden recession of the sacrum, and 
that they who have assumed that in the female there is a more abrupt 
recession of the sacrum, are as much in error as those who have de- 
scribed the female sacrum to be more curved than the male. The 
symphysis forms with the horizon an angle of 35° to 40° in the erect 
posture; while the ischium forms with the ilium, or rather with the 
imaginary line leading downwards and forwards, and representing the 
mean direction of that bone, an angle of 110° to 115°. This latter is 
called the ilio-ischial angle? 

Development of the Pelvis. — From birth to the age of puberty, the 
pelvis differs in many respects, besides mere size and state of ossifica- 
tion, from the same part in the adult. At birth, the iliac fossa? are flat, 
and have their surfaces directed more forwards. The symphysis is 
short. The sacrum is very narrow, and on this account the transverse 
measurements are relatively smaller than the conjugate; while all the 
diameters are extremely small, and so insufficient for the reception of 
what are known as pelvic organs, that these parts are for the most part 
lodged in the abdominal cavity. This contributes, no doubt, to the 
abdominal prominence which is so familiar in the newly born. The 
sacrum is very flat, and there is also very little approximation of the 
inner surfaces of the ischium, which gives to the sides of the pelvis a 
general appearance of parallelism not existing in the adult. A very 
general idea prevails among the best modern writers that the inclination 
of the brim is considerably increased as compared with the adult. 
This has been stated by Cruveilhier and Burns, and even more decid- 
edly by Cazeaux. " The sacrum," says the latter, " is so flat and so 

1 For a complete and exhaustive aVniv>nstration of these and other points alluded 
to, see Mr. Wood's Essay, Art. "Pelvis " in Todd's Cyclopaedia. 




II.] FLOOR OF THE PELVIS. 47 

elevated, that a horizontal line drawn from the upper part of the pubis 
will pass below the coccyx." Mr. Wood, however, has given the 
weight of his authority in favor of another view, and states it as the 
result of his careful observations, made by sections when the soft parts 
were in situ, that he has always found the tip of the coccyx " as low as 
the lower border of the symphysis pubis." Such a serious discrepancy 
can only be accounted for by supposing that a different mode of obser- 
vation has been adopted. 

The child, it must be remembered, is not as yet structurally fit for 
the erect position, and therefore maintains for many months after birth 
a posture similar to that which it assumes in the womb, with the thighs 
flexed upon the abdomen, and the symphysis tilted upwards. To 
measure the pelvic angles of the child, with the view 
of comparing them with those of the adult, it is es- FlG - 17 - 

sential that the child should be placed in such a posi- 
tion as may, without violence or rupture of tissue, 
coincide as nearly as possible with the erect posture, 
and if this is done the pelvis will usually be found to 
present the appearance shown in Fig. 17. From this 
point of view Cazeaux is possibly correct ; but if a 
section be made through a child in the position which 
it instinctively adopts, the relative position of parts, 
as described and figured by Mr. Wood, will probably 
under these circumstances be confirmed. The other distinctive char- 
acteristics of the infant pelvis are also shown in the figure, in which, 
moreover, the general resemblance to the type of the Simiina may 
afford some pleasing suggestions to the disciples of Darwin. 

According to Burns, it is not until the tenth year that the transverse 
comes to exceed the conjugate measurement. There is, however, noth- 
ing which would enable us to distinguish with even an approach to 
certainty between the male and female pelvis until the period of puberty 
approaches, when nature, availing herself of the plastic nature of these 
bones, due to their tardy ossification, moulds the parts, in full view of 
the important physiological function which is about to be instituted, 
so that the marked characteristic features of the female pelvis are now 
rapidly developed. 

Hitherto we have looked at the pelvis as an osseous and ligamentous 
structure. Connected in the most intimate manner with it, however, 
there are certain soft structures which cannot properly be included in a 
description of the organs of generation, and which fall therefore to be 
considered' in this place. The fan-shaped iliacus muscle forms, along 
with the psoas on each side, a sort of cushion, which, besides giving 
proper support to other viscera, forms a rest for the gravid uterus, and 
an effectual protection for it against shock. It encroaches, as we have 
seen, upon the transverse, without materially lessening the oblique 
diameter, and this encroachment is more marked when the muscles are 
in a state of contraction. On each side of the cavity, there are two 
muscles covering in to a great extent the great sciatic and obturator 
gaps. These are the pyriformis and obturator internus muscles, to the 
contraction of which the rotation of the foetal head which takes place 



48 FEMALE ORGANS OF GENERATION. [CHAP. 

within the cavity was supposed by Flam and of Strassburg to be due. 
The dimensions of the cavity are further reduced by the rectum and 
bladder, and by the cellular tissue, which, when overcharged with fat, 
may form a barrier to the progress of labor, rendering its course more 
tedious. 

The perineal strait, open in the skeleton, is occupied by firm con- 
tractile tissues, which form a floor for the support of the pelvic, and, 
indirectly, of the abdominal viscera. This floor consists of two mus- 
cular layers. Of these, the internal layer, formed by the levator ani 
and cocci/geus, has its concavity directed upwards, and has been named, 
not inappropriately, by Meyer the "pelvic diaphragm." The external 
layer, with its concavity downwards, is formed of the muscles of the 
perineum, known to anatomists as the sphincter ani, transversus perinei, 
ischio- caver mosus, and sphincter vagince. The pudic vessels and nerves, 
cellular tissue, the pelvic aponeurosis, an intermuscular aponeurosis, 
and the skin, complete this floor, which at the time of delivery becomes 
thin and distends to a very considerable extent. In the ordinary state, 
the measurement from the coccyx to the posterior commissure of the 
vulva is a little more than three inches ; but, during labor, the disten- 
sion is such that it is increased to 5, 6, 6J inches, or even more, by the 
stretching of the parts, and by overcoming the tonic contraction of the 
sphincter. 



CHAPTER III. 

FEMALE ORGANS OF GENERATION. 

A. External: labia; perineum; hymen, etc. — erectile tissue — the va- 

gina — GLANDS OF THE EXTERNAL ORGANS — ABNORMAL CONDITIONS — MAM- 
MARY GLANDS. 

B. Internal: the uterus: situation of; divided into body and cervix, 

AXIS OF UNIMPREGNATED UTERUS; CAVITY OF; FUNDUS; SURFACES AND 
BORDERS — SEROUS COVERING OF — BROAD LIGAMENTS; ROUND LIGAMENTS; 
VESICO-UTERINE FOLDS — THE FALLOPIAN TUBES — PAROVARIUM — FOLDS OF 
DOUGLAS — EQUILIBRIUM OF THE UTERUS. 

The Organs of Generation in the female include — besides the Uterus, 
Ovaries, and other parts situated internally — the Vagina, Vulva, and 
Mons Veneris. These latter being, more properly, external organs, 
anatomists have divided the whole into External and Internal Organs. 

External Organs of Generation. — Immediately over the symphysis 
pubis, above, and in front of the opening of the vulva or pudendum, is 
a firm cushion-like eminence, about two inches in depth and three 
inches transversely. This, which is called the Mons Veneris, varies in 
prominence according to the conformation of the pubes, and the amount 
of adipose and cellular tissue in it and the contiguous parts. After 



III.] THE PERINEUM. 49 

puberty, it is covered with hair, and is abundantly furnished with 
sebaceous follicles, which were supposed by Moreau to contribute in some 
measure to the dilatation of the external parts at the moment of delivery. 
Continuous with this structure, extending downwards and backwards, 
and becoming gradually thinner in their course, are two rounded folds 
of integument, which, diverging from each other, leave in the median 
line an elliptical interval between them. These, are the labia majora, 
labia externa, or labia pudendi. They present an external surface, 
lined with skin similar to that of the mons veneris, and an internal 
surface covered with mucous membrane, which is the commencement of 
the genito-urinary tract. Behind, the thinner margins unite, forming 
the posterior commissure of the vagina. The fourchette, or framidum 
pudendi, is a transverse fold in front of this, which resembles and has 
been aptly compared to the continuation of the skin at the roots of the 
fingers, and is very generally torn in first labors. The depression 
between the fourchette and the commissure is named the fossa navicu- 
laris. Between the skin and superficial fascia of the labia there exists 
a purse-shaped sac, which has been described by M. Broca as analogous 
to the dartos tunic of the scrotum. This sac is filled with fat and cel- 
lular tissue, is the receptacle occasionally of hernia, and to it have been 
traced the terminal fibres of the round ligament of the uterus. 

The perineum extends from the posterior commissure to the anus, 
and is usually about an inch and a half in length. It is made up of 
highly distensible cellular tissue, and has been said to contain some 
yellow elastic tissue. It is undoubtedly susceptible of great distension 
during labor, without, under ordinary circumstances, any risk of rup- 
ture. 

On separating the labia majora, the labia minora or nymphaz are 
brought into view. These are two thick mucous folds, somewhat 
resembling the comb of a cock, about an inch and a half in length, 
having their origin on the inner surface of the labia majora, and 
becoming wider as they pass upwards and forwards, converging towards 
the clitoris, with the prepuce of which they are continuous. The 
clitoris is a small erectile tubercle, situated somewhat above the level 
of the lower margin of the symphysis pubis. Like the penis of the 
male, it has a suspensory ligament, two crura, two corpora cavernosa, 
and a glans, but has no corpus spongiosum nor urethra. Two muscles, 
corresponding to the ischio-cavernosus, are in the female called "erec- 
tores clitoridis." The vestibule is a small triangular space, bounded 
above by the clitoris, below by the urethra, and on either side by the 
diverging nymphse. It is about an inch in length, is smooth on the 
surface, and is specially important as a guide to the finger of the 
accoucheur in the introduction of the catheter — an operation which 
should always be performed, if possible, without exposing the patient. 
The meatus urinarius is indicated by a small projection, easily dis- 
covered by the finger, immediately beneath the vestibule, and in front 
of the vaginal entrance. The catheter being laid along the palmar 
surface of the forefinger, its point is guided towards the projection just 
mentioned, when, if the other extremity is gently depressed, it will 
usually pass in without the slightest difficulty. When the parts are 

4 



50 FEMALE ORGANS OF GENERATION. [CHAP. 

distorted by disease, or by the tumefaction which occurs after labor, it 
is often necessary to expose the patient before the instrument can be 
introduced. The urethra is about one inch to one inch and a half in 
length, highly distensible, and, in the unimpregnated state, almost 
straight. In young children, what may be called the urinary parts of 
the vulva are prominent, and it is not till the approach of puberty that 
the genital portion is observed to predominate. 

Behind and beneath the meatus, is the orifice of the Vagina, varying 
greatly in appearance and in dimension in young girls, in those who 
are no longer virgins, and in those who have borne children. In vir- 
gins, it is generally closed to a considerable extent by a thin fold of 
the mucous membrane called the hymen, which was at one time sup- 
posed to be the "seal of virginity/' but which may be ruptured by 
many causes other than coitus. Its usual form is crescentic, with the 
concavity upwards, closing in the posterior, and to some extent the 
lateral portions of the opening ; but it may present itself under various 
other forms. It has been frequently observed, for example, to be cir- 
cular, with a small perforation in the centre; or cribriform, with sev- 
eral perforations, as in a medico-legal case which the writer was called 
upon to examine ; or infundibuliform, or offering rarer peculiarities. 
In some instances, the closure is complete. But, whether complete or 
partial, or under whatsoever form it may present itself, the first effects 
of coitus are generally sufficient to rupture this fragile partition. In 
rare cases, however, its texture is so firm and resistant, that penetration 
is rendered impossible until the structure has been divided by the 
scalpel; and in cases of complete closure, where there is no question of 
coition, the operation may be necessitated from its being a barrier to 
the menstrual flow. 

When the hymen is absent, small projections, called caruneulce myrti- 
formes, generally about three or four on each side, are noticed on the 
margins of the opening. These were generally supposed to be the 
remnant of the ruptured hymen ; but, as they have been found to exist 
along with the hymen, this must be looked upon as open to doubt. 

Bloodvessels are supplied in abundance to all parts of the external 
generative organs, and in certain situations the masses of venous plex- 
uses which are termed erectile tissue are found in considerable quantity. 
The accompanying cut, from Kobelt, shows these structures carefully 
dissected. Besides the erectile parts already mentioned, there are, on 
either side of the vaginal orifice, two large leech-shaped masses, a, called 
bulbi vestibuli, which are about an inch in length, and are connected 
with the crura of the clitoris and the rami of the pubis, covered inter- 
nally by the mucous membrane, and embraced on the outside by the 
fibres of the constrictor vaginse muscle. A small plexus — the pars 
intermedia of Kobelt — has direct vascular connection with the bulbs. 
These erectile tissues receive their blood from the internal pudic 
arteries. 

The Vagina is a membranous and highly dilatable tube, which serves 
to connect the vulva with the uterus. It is situated in the true pelvis, 
between the bladder and rectum anteriorly and posteriorly, and the 
levatores ani muscles at the sides. Its axis is a curve, which corre- 



III.] 



THE VAGINA. 



51 



sponds in some degree to that of the pelvis ; and, in consequence, its 
anterior is shorter than its posterior wall, the former being about four, 
and the latter five or six inches in length. It is narrowest at the vulva, 
where it is embraced by the constrictor vaginae muscle, and widest at 
its middle part, where it is extended transversely, owing to its being 
compressed by the organs before and behind. The thickest part of the 



Fig. 18. 




External organs, partially dissected. (Kobelt.) 



tube is its anterior wall, where it is intimately connected with the 
bladder, and with the urethra, which is, as it were, imbedded in it. 
Its connection with the levatores ani muscles and the rectum is much 
looser, which admits of easy dilatation, and which also accounts for the 
fact that the rectum is rarely dragged down in uterine displacements, 
while the bladder is, from its closer connection, almost invariably 
altered in its relations. In the upper part of its posterior surface, it is 
separated from the rectum by a double fold of serous membrane, which 
forms a pouch of the peritoneal cavity. 

The external surface of the vagina is composed mainly of dense 
areolar tissue, beneath which there are two indistinct layers of muscu- 
lar fibres of the unstriped variety, the external being disposed longi- 
tudinally, while the internal are circular in their direction. Around 
the tube, a layer of loose erectile tissue has been found, which is most 
distinct at the lower part. Internally, it is lined throughout by mu- 
cous membrane, w T hich is covered with epithelium of the squamous 
variety, and is continuous in one direction with the skin and in the 
other with the mucous membrane of the uterus. Along the anterior 
and posterior walls, the membrane is slightly raised in the middle line, 
so as to form a ridge similar to the raphe in other parts. These ridges 
are called columnce rug arum ; and, at right angles to them, the mem- 
brane is thrown into numerous transverse folds (rugce), which are always 



52 



FEMALE ORGANS OF GENERATION. 



[CHAP. 



more distinct in those who have not borne children, and which are 
obviously destined to facilitate the dilatation of the parts. 

The upper part of the vagina embraces the neck of the uterus, which 
projects into the cavity from above, and in front. The vaginal mucous 
membrane is consequently reflected over the neck of the uterus some 



way above its mouth, the point of reflection 



being 



higher 



on 



the 



Fig. 19. 




Showing the relative position of the pelvic organs. 



posterior wall ; and it has been observed that the connection between 
the membranes and the subjacent uterine tissue is very firm close to the 
mouth of the womb, and is much less so as it approaches the point of 
reflection. This admits of the complete dilatation of the uterus, and 
the consequent obliteration of the neck. The other tissues of the 
vagina are continuous, or at least very closely united, with the corre- 
sponding tissues of the uterus. A reference to Fig. 19 will serve to 
show that the vagina terminates in a cul-de-sac above and behind the 
uterus, and that at this point its wall is for some distance in direct rela- 
tion with the peritoneal cavity, a fact of no little practical importance. 
The cul-de-sac of peritoneum with which it is in contact is termed the 
recto-vaginal pouch, and sometimes the pouch of Douglas. 

Further, the vagina may be considered as the organ of copulation in 
women • and as the canal which is destined to transmit the menstrual 
discharge, and, in case of pregnancy, the product of conception. It is 
abundantly supplied with vessels and nerves. The blood supply is 



III.] THE VAGINA. 53 

derived from the vaginal and other branches of the internal iliac artery, 
and returns by means of corresponding veins, after forming at each 
side a vaginal plexus. The nerves have been traced to two sources, 
the hypogastric plexus of the sympathetic system, and the fourth sacral 
and pudic nerves of the spinal system. 

The external organs of generation are furnished with numerous 
glands of various kinds, which have been very fully described by MM. 
Robert and Hugnier. The latter divides the glands of the vulva and 
entrance of the vagina into sebaceous and muciparous follicles. The 
sebaceous variety is met with in great abundance over the whole of the 
parts from the genito-crural folds to the clitoris and nymphse. Those 
of the nymphse are exclusively sebaceous, and they all find their func- 
tion in the secretion of an oily fluid, which maintains the elasticity, 
moisture, and sensibility of the parts, prevents them from adhering, 
and, above all, protects them from the irritating action of the urine. 
The muciparous follicles differ essentially in their situation, and in the 
nature of the fluid which they secrete. Although here and there they 
are isolated, as a general rule they are found in groups. One such 
group of eight or ten follicles is found imbedded in the mucous mem- 
brane of the vestibule. Another is observed in the immediate neigh- 
borhood of the meatus urinarius, their orifices being extremely minute, 
and opening for the most part below the aperture of the meatus, upon, 
or close to, the little tubercle already described. A third group is 
described as external to these, and situated on either side of the urethra ; 
and a fourth, the orifices of which have been observed on each side of 
the vaginal opening, at the root of the hymen or carunculae myrti- 
formes. 

Under the muciparous class, two compound or conglomerate glands 
were long ago described by Bertholin, and more recently by anatomists 
under the name of the vulvo-vaginal glands. They are also called the 
glands of Duvernay, and are in many respects analogous to Cowper's 
glands in the male. They are about the size of a small bean, variable 
in form, and of a reddish-yellow color. Their development is said to 
proceed, pari passu, with that of the ovaries, reaching the maximum 
during the child bearing period, and being comparatively insignificant 
in youth and old age. They are situated one on each side, at the 
entrance of the vagina, beneath the superficial fascia, with their inner 
surface united to the vagina by areolar tissue, and the outer surface in 
relation with the constrictor muscle of the vagina. Each of the lobes 
of which the gland is composed gives origin to a little duct, all of which 
conduits ultimately unite at the internal and upper part, to form a com- 
mon excretory duct, which proceeds horizontally forwards as far as the 
vaginal orifice, where it terminates within the nymphse, and external to 
the hymen or carunculae myrtiformes. The orifice is very small and 
valvular, and is often only to be discovered with difficulty ; but its 
situation is usually indicated by an increased vascularity at the point 
whence it emerges. These glands secrete a fluid resembling that which 
is found in the prostate in the male, which is increased in quantity 
during coition, and is said to be expelled in jets, as occasionally occurs 
with the contents of the salivary duct. By lubricating the parts it 



51 FEMALE ORGANS OF GENERATION. [CHAP. 

facilitates coition, and by preserving their moisture probably tends to 
maintain their extreme sensibility. 

The appearance and anatomical relations of the external organs of 
generation vary greatly according to age, and in consequence of vene- 
real indulgence, or of childbearing. At birth, the nymphse project 
beyond the level of the labia majora, and the parts in general look more 
forward than in the adult. When puberty approaches, hair appears on 
the pubes, the nympha? disappear between the labia, and the parts look 
downwards, so that in the erect posture nothing can be seen from before 
except the mons veneris ; whereas, in the child, the upper parts of the 
vulva are distinctly visible. The labia are symmetrical, thicker above 
than below, closely applied to each other, and of a fresh rose color on 
their mucous surfaces. Venereal indulgence, and still more, pregnancy 
and childbearing, modify, in a great measure, the appearance here 
described. The hymen is ruptured and replaced by the carunculse 
myrtiformes. The labia lose their regularity, and become of a more 
dingy hue on their mucous surface. The nymphae come again into 
view, partly by separation of the labia, and partly in consequence of 
hypertrophy of their tissue, while their vivid rose tint becomes replaced 
by a darker shade of color. In some cases the hypertrophy is very 
remarkable, and when so, is usually unequal on the two sides. This 
is said to be very common among Hottentot women, where the nymphse 
often become enormously enlarged. In women who have borne children 
the fourchette is usually ruptured, and the vaginal orifice remains large 
and irregular. The vagina again, which in virgins presents the appear- 
ances already described, may now lose, to a great extent, its rugae; and 
the deepening of its color is by some supposed to be a not unimportant 
sign of pregnancy. In women of advanced age, the vagina becomes 
contracted, being again thrown into folds, and greatly diminished in 
calibre. Its orifice shares in the contraction, the nymphre shrink, and 
the labia majora come once more into proximity, while the glandular, 
erectile, and other special tissues become atrophied. In a word, the 
characteristics of childhood are again in a great measure restored. 

Abnormal conditions, constituting some form or other of congenital 
malformation, are occasionally met with in the external organs. The 
labia may be imperfect or rudimentary, preserving in this respect the 
foetal condition of the parts; they may be developed on one side only; 
or they may present the appearance of several folds. In cases of 
deficiency of the lower part of the abdominal wall and of the bladder, 
along with separation of the symphysis pubis, the labia are imperfectly 
formed and set wider apart than usual. The posterior commissure of 
the vaginal orifice may be hypertrophied and pushed forwards so as to 
cover the aperture. The labia are, in some instances, adherent along 
the median line, to such an extent that an opening is left sufficient only 
for the passage of the urine. Induration and hypertrophy such as to 
constitute elephantiasis has also, although rarely, been noticed. Entire 
absence of the clitoris, unassociated with any other form of malforma- 
tion, is very rare. It is sometimes so small that it can with difficulty 
be discovered, and in these cases it might be erroneously supposed to 
be absent ; but it may be assumed that, unless other parts, such as the 



III.] MAMMARY GLANDS. 55 

nymphse, are absent, the clitoris is only rudimentary. This organ is 
much more frequently enlarged, generally, no doubt, as the result of 
disease, but sometimes it is a pure hypertrophy of the normal tissues, 
when it may approach the dimensions of the penis and constitute one 
of the so-called forms of hermaphroditism. An extreme development 
of the nymphse — common, as we have seen, in certain races — may 
occasionally be met with as a peculiarity of structure ; and cases are 
even recorded where they have been found increased to two or even 
three pairs. 

The folds of which the hymen is composed, ordinarily thin and 
fragile, are occasionally developed to such an extent as to prevent 
sexual congress ; while, in some cases, it completely closes the mouth 
of the vagina, preventing not only coition and impregnation, but also 
menstruation, and, for the latter reason, if not for the former, rendering 
an operation necessary — which is usually a very simple one. Another 
condition of these parts which may call for operative interference, is 
what has been called vaginismus, where there exists such spasmodic 
contraction as prevents proper sexual contact, dilatation with or without 
the use of the scalpel being in such cases often found necessary. Con- 
genital absence of the vagina is by no means of very rare occurrence. 
In extreme cases, the whole organ is wanting — the vulva terminating 
abruptly at the point where the vagina, in the ordinary condition of 
parts, commences. In others, a portion of the tube exists, but ends in 
a cul-de-sac at some distance from the os uteri ; while, in another class, 
there is a narrow canal, sufficient only for the passage of the menstrual 
fluid. In many of these cases, free incision may be found necessary, 
in order, by giving egress to the menstrual discharge, to relieve the 
serious symptoms which arrest of that important function is apt to 
engender. 

A vertical septum occasionally exists, constituting the phenomenon 
of double vagina, in which, if complete, there is a hymen to each tube. 
More frequently, however, the septum is incomplete — either commenc- 
ing at the vulva and terminating so as. to leave the tube single at its 
upper part, or, conversely, commencing at the upper part and stopping 
short of the mouth of the vagina. In the latter case, we would expect 
it to be associated with double uterus. Transverse membranous septa 
also exist as congenital malformations, but much more frequently as 
the result of inflammatory action, or of the accidents of previous labors. 

Many of the conditions above detailed may give rise to serious im- 
pediments, either to delivery, to impregnation, or to the proper per- 
formance of the menstrual function, and, in consequence, delicate, and 
even dangerous operations may under such circumstances be required. 

Mammary Glands. — Intimately associated with the function of the 
reproductive system, are the glands, the presence of which serve to 
distinguish the class Mammalia. On this account, several modern 
writers have, with perfect propriety, included these organs in a descrip- 
tion of the external parts of generation. When they are fully devel- 
oped in a woman, they extend from the third to the sixth or seventh 
rib, and from the side of the sternum to the axilla, the left breast being 
generally the larger of the two. The nipple (niamilla) projects about 



56 



FEMALE ORGANS OF GENERATION. 



[CHAP. 



the level of the fourth rib from near the centre of the gland, and is, in 
the virgin, of a rose pink color. It is surrounded by a ring of similar 
hue (areola) varying in tint with the complexion of the individual. 
On the surface of this, several small tubercular projections are visible, 
on each of which are the orifices of several glands. 1 The tissue of the 
nipple is very rich in bloodvessels, and contains muscular fibres of the 
non-striated variety with a certain amount of erectile tissue, the surface 
being covered with papillae, which are highly sensitive. The tumes- 
cence of the nipple, which occurs under irritation, is usually attended 
with a pleasurable sensation. 

The bulk of the breasts, and what gives to them their smooth and 
moulded form, is chiefly fat, which, except at the nipple and areola, 
where the gland is contiguous to the surface, lies beneath the skin, and 
dips down into the intervals between the lobes and lobules of which 
the gland is composed. Each of these lobes is inclosed in a distinct 
cavity {loeulus, Fig. 20, 4), has a separate excretory duct, and is sub- 
divided again and again into smaller lobes, and ultimately into termi- 

Fig. 20. 




Dissection of the lower half of the female mamma during the period of lactation. (Luschka.) 

nal lobules. Within the latter, by a process of cell development, and 
multiplication of nuclei, the milk is eliminated from the surrounding 
vessels. The fluid, on the rupture of the cells, passes into the terminal 
ramifications of the ducts; which by their junction form larger canals 
termed galactophorous ducts. The milk being thus brought from the 
various lobes, these ducts, from fifteen to twenty in number, converge 



1 These appearances are materially altered after impregnation. See Signs of 
Pregnancy. 



III.] 



AMMARY GLANDS. 



57 



towards the areola, beneath which they become considerably dilated 
into sinuses, 6, which serve as temporary reservoirs for the milk against 
the period of suckling. Between this and the nipple, the ducts again 
become contracted, 5, and proceed from the base of the nipple towards 
its summit without communicating, each discharging its contents by a 
special orifice. The walls of the tubes and sinuses are composed of 
areolar tissue, with longitudinal and circular elastic filaments. Irrita- 
tion of the nipple, either by the contact of the child or otherwise, 
causes a relaxation of the orifices, and at the same time, contraction of 
the walls of the sinuses, which may be looked upon as a reflex action, 
and which causes the milk to flow abundantly. Not unfrequently, a 
spasmodic contraction takes place independently of any special excite- 
ment, the result being the involuntary expulsion and loss of the milk. 
The well-known sympathy which subsists between the glands and other 
organs, such as the stomach and uterus, may give rise to similar phe- 
nomena; while that which exists between the breasts of each side often 
results in the spasmodic emptying of one gland while the child is at 
the other. 

'The lacteal vessels are lined throughout by a mucous membrane, 
continuous at the nipple with the common integument, and which is 
invested by a tessellated epithelium. They are accompanied in their 
whole course by numerous lymphatics, which are connected intimately 
with those of the axilla and other neighboring parts. These lym- 
phatics are believed to take up the watery portion of the milk, and it is 
supposed to be by their action that frictions are beneficial in cases where 
we wish to diminish or arrest the secretion of milk. They receive their 



Fig. 21. 



Fig. 22. 




.^V^v 



K^ 




Structure of a lobule of the mammary 
gland. 




Ultimate glandular vesicles 
of the mamma. 



blood from the internal mammary, axillary, and intercostal arteries. 
The veins form round the nipple a circle or plexus, which is usually 
called the cir cuius venosus of Haller. In the latter months of preg- 
nancy, the pressure of the gravid uterus tends, as Mr. Nunn has pointed 
out, to increase from mechanical causes the quantity of blood in these 
vessels, and thus to promote the secretion of the gland. 

Fig. 21, from Henle, represents a section from a small lobule of the 
gland, magnified 60 diameters. 1, shows the stroma of the connective 
tissue which supports the glandular structure ; 2, terminal ramuscule 



58 FEMALE ORGANS OP GENERATION. [CHAP. 

of one of the gland tubes ; 3, glandular vesicles. Fig. 22 shows several 
of the glandular vesicles, magnified much more highly, about 200 
diameters. The secreting epithelial cells which line the vesicles are 
here represented, while the cavities contain a certain number of milk 
globules. 

In the male, the mammary gland exists, but is rudimentary. Various 
anomalies in structure have been met with, such as two or three nipples 
on one gland, or an additional mamma or even mammae. In the latter 
case, the supernumerary glands are usually near their ordinary site, 
but sometimes they have been found in a distant part of the body — as 
the axilla, thigh, or back. 

The Internal Organs of Generation. — These are the Uterus, 
the Fallopian Tubes, the Ovaries, with various ligamentous and other 
structures intimately connected with them. 

The Uterus, when unimpregnated, and at mature age, is, situated 
deeply within the true pelvis, between the bladder and the rectum in 
front and behind, and intimately connected at its lower part, as we 
have already seen, with the vaginal wall. The function which it has 
to discharge, is to receive the product of conception after it has passed 
through the Fallopian tube, and to maintain it within its cavity until, 
at maturity, it is expelled. The usual comparison of it to a pear, 
flattened from before backwards, gives one a very correct idea of its 
form. It is a hollow organ, with remarkably thick walls; and is so 
placed in the centre of the pelvis, that its upper part looks upwards 
and forwards, and its lower or vaginal part downwards and backwards. 
It is generally assumed, as sufficiently correct for all practical purposes, 
although by no means absolutely accurate, that its axis corresponds 
with that of the pelvic brim, or, in other words, that its axis, if carried 
downwards, would pass at the same time backwards, and cut the horizon 
at an angle of 30°. 

The uterus is divided into two parts : the body, which is much 
broader ; and the neck, which is nearly as long as the body, but much 
narrower. The point of division between these two parts is frequently 
indicated externally by a slight constriction. 

Till about the fourteenth or fifteenth year, this organ is of small size, 
but a considerable increase takes place at the period of puberty. In 
women who have borne children, its volume is permanently increased, 
although it is sometimes found in advanced age to have resumed in 
some measure the appearance presented in early life. It is temporarily 
increased in size during a menstrual period ; but if examined during 
the interval, the virgin uterus will be found to weigh on an average 
about 500 grains, and to measure, in length three inches, in breadth 
about two inches, and in thickness (i. e., from before backwards) one 
inch. Its situation varies according to age. In the foetus it is alto- 
gether above the brim, but from this position it gradually descends 
after birth, although it is not till the tenth year or even later that the 
fundus falls to the level of the brim plane. The uterus is, when healthy 
and normal, united with the surrounding parts by means of certain 
structures to be described presently. The nature of this union is essen- 



III.] 



THE UTEKUS. 



59 



tially lax, admitting of pretty free movement in all directions, which 
may easily be tested by the finger, and which enables it to accommo- 
date its position according to the degree of distension of the neighbor- 
ing hollow viscera. This laxity admits too of the free expansion of 
the uterus during the course of pregnancy, but unfortunately it may 
also give rise to certain displacements which will be duly considered 
in the proper place, in so far as these have a bearing upon the practice 
of midwifery. These displacements are prolapse or jwociclentia ; ante- 
version and anteflexion; retroversion and retroflexion; and lateral dis- 
placements ; terms which require no explanation. 

The axis of the virgin uterus must, therefore, be constantly chang- 
ing, now backwards and now forwards, according as vesical or rectal 
distension prevails. It is thus a matter of no little difficulty to deter- 
mine what may be regarded as the normal axis of the uterus, and in 
all attempts which have been made by anatomists with this view, it 
has been usual to consider the parts to be in their normal relative posi- 
tion when the bladder and rectum are each moderately distended. The 
opinion which is usually adopted, and which is founded on estimates 
of this nature, is, as has been said, that the axis of the uterus is iden- 
tical with the axis of the pelvic brim. It is admitted that, in many 
cases, and especially in those in which the vagina is very short, the 
fundus falls more or less backwards so as to bring the uterine axis 
more into a line with that of the vagina, while in some cases the uterus 
is curved so that the body forms an angle with the neck. 

This bending of the uterine axis, instead of being admitted as an 
exception, is recognized by many of the best authorities as the normal 
position of the womb, a view which careful personal observations leads 
us to confirm. It is a point of 

great importance, in making fig. 23. 

examinations on the living sub- 
ject, that it should be clearly 
recognized that the finger, on a 
digital examination, approaches 
the os uteri in a direction cor- 
responding to the axis of the 
vagina, which frequently forms 
nearly a right angle with the 
uterus. If this is overlooked, 
error is sure to creep into our 
calculations, as has evidently 
been the case in certain instances 
of inaccurate description of the 
anatomical relations of the 
womb. The opinion here ex- 
pressed as to the position of the 
womb is in accordance with that 
of Kohlrausch, as shown in his 
plates, and is confirmed by Dr. 
A. Farre in his admirable essay 
in the Cyclopaedia of Anatomy and Physiology, from which the diagram 




Diagram, showing relative position of pelvic viscera. 
(A. Farre.) 



60 



FEMALE ORGANS OF GENERATION. 



[CHAP. 



(Fig. 23) is taken. According to these able observers, when the blad- 
der b and the rectum c are moderately distended, the fundus of the 
uterus is directed upwards and forwards, and the neck downwards and 
very slightly backwards towards the orifice of the rectum. The relative 
heights of these parts are determined, it is assumed, by two lines : the 
one, a — a, being drawn from the lower border of the symphysis pubis 
to the promontory of the sacrum, to mark the height of the fundus; 
and the other, b — 6, carried from the same point anteriorly to the lower 
margin of the fourth sacral vertebra behind, to mark the plane of the 
orifice of the uterus. The line c — c indicates the axis of the body of 
the uterus. The representation, therefore, given in Fig. 23, is, as re- 
gards the position of the womb, probably nearly correct, subject, of 
course, to numerous modifications, in consequence of its mobility, and 
the influence exercised upon it by neighboring organs. 

The interior of the uterus corresponds in some measure with its ex- 
ternal surface. It is divided into two parts by a constriction not far 
below its middle, indicating the point at which the cavity of the cervix 
ends, and that of the body begins. This constriction, which is the 
usual cause of the difficulty experienced in passing the instrument 
known as the uterine sound, is called the os uteri internum, the orifice 
communicating with the vagina being named the os tinccje, os externum, 
or, more generally, the os uteri. In a profile section (Fig. 24) the an- 



Fig. 24. 



Fig. 25. 




^^W 




Profile sectipn of the uterus. 



Lateral section of the uterus. 



terior and posterior walls are shown to be almost in apposition, this 
being, however, more complete at the internal os o. From this point 
the cavity of the body extends upwards to the fundus, while that of the 
cervix reaches downwards, and terminates at the external 



os. 



The 

neck of the uterus is divided, as will be observed, into two portions, 
upper and lower, by the point of reflection of the vaginal mucous mem- 



III.] 



THE UTERUS. 



61 



brane, the lower part being called the vaginal part of the cervix. 
Viewed thus, the os is composed, as may be noticed, of two lips, a, an- 
terior, and p, posterior, of which the former is generally described as 
the longer. This, however, which is more apparent than real, is caused 
by the position of the uterus as regards the pelvis, which brings the 
anterior lip lower in the vagina, and thus makes it seem longer than it 
really is in reference to the long axis of the organs. The vagina 
reaches somewhat higher on the posterior than it does on the an- 
terior lip. 

If we now make a transverse section as shown in the accompanying 
diagram (Fig. 25), it is to be noticed, in the first place, that the cavity 
of the cervix, as well as that of the body, is expanded from side to side, 
owing to the approximation of the anterior and posterior walls as shown 
in the previous figure. The cavity of the cervix then is, being some- 
what flattened from before backward, irregularly fusiform. Its lining 
membrane presents a peculiar appearance, being thrown into irregular 
folds, which branch laterally from a raphe or median line, in a direc- 
tion generally upwards. This arborescent appearance has given rise to 
the name under which it is known to anatomists, the arbor vitce uterinas, 
and it has been observed that, in the uteri of very young children, 
these folds are traced much higher than in the internal os, which is 
their limit in the adult. The cavity of the body is from this point of 
view triangular in shape, smooth on its surface, and having three open- 
ings leading into it, one at the internal os or apex of the triangle, and 
one at each angle of the uterus, leading right and left into the Fallopian 
tubes. Some rare instances of congenital absence of this cavity have 
been recorded: what is more common is adhesion of the walls in old 
age. 

The os uteri, as felt by the finger, or as seen through the speculum, 
is a transverse opening or slit, which, in the virgin, and in the ab- 
sence of structural disease, is perfectly 
smooth. In these circumstances, the 
aperture is closed, but the depression 
between the lips is easily felt, and is 
precisely similar, in the impression it 
communicates to the finger, to the sen- 
sation experienced when the finger is 
applied to the tip of the nose. In this 
case the cartilages represent the firm 
tissue of the lips, while the vertical in- 
terval between them corresponds to the 
transverse slit which constitutes the os. 

The characteristics above described are those of the virgin, or, as 
Dr. Tyler Smith more correctly calls it, the " nulliparous " uterus. 
During pregnancy, the organ is enormously distended, and the ana- 
tomical relations of the contiguous parts are greatly disturbed. After 
delivery, the parts contract, and regain in a great measure their original 
appearance and condition, but they nevertheless retain features of dis- 
similarity which generally enable the observer, on a careful examina- 
tion, to distinguish the uterus of a woman who has been a mother. The 



Fig. 26. 




62 FEMALE ORGANS OF GENERATION. [CHAP. 

chief points of distinction are as follows : The weight of the organ is 
increased, according to Meckel, to about an ounce and a half; the 
fundus and body are rounded externally ; the cavity of the body loses 
its triangular shape, and becomes much larger relatively to the cervix, 
the os internum being agape. The arborescent folds of the cervix are 
in a great measure obliterated, or at least are rendered indistinct, and 
the os externum is patent. The differences in the latter are, from the 
fact of its being of easy access to the finger, of special importance, and 
consist mainly in an enlargement of the parts, and an irregularity in 
the surface of the lips, which are now no longer smooth, but puckered 
round the edge of the os, and often nodulated on the surface. These 
irregularities are due to slight lacerations of tissue which occur during 
delivery. They are always more marked in women who have borne 
many children, where the lips are not unfrequently divided into lobes 
by shallow furrows, representing these lacerations, and which radiate 
from the os as from a centre. These fissures are generally observed 
at the sides or angles of the os, and are, according to Cazeaux, much 
more marked on the left than on the right side. 

The uterus, then, as may be inferred from what has been said, pre- 
sents a fundus, more or less rounded according as the woman has or 
has not borne children, two borders laterally, and an anterior and 
posterior surface, of which the latter is the more convex. It consists 
of three constituent layers : a serous or investing coat ; a mucous or 
lining coat ; and an intermediate thick layer of fibro-muscular structure 
constituting the proper tissue of the uterus. Each of these requires 
special and very careful consideration. 

The Sei*ous Coat — Along with this, we shall consider certain structures 
very intimately connected with it, which are described as the Ligaments 
of the Uterus. The great serous membrane, which invests almost the 
whole of the abdominal viscera, is also reflected over the greater part 
of the womb. Passing backwards over the fundus of the bladder, the 
peritoneum becomes reflected upwards on the anterior surface of the 
uterus from a point which in the virgin uterus is about midway between 
the os externum and internum, a space being thus left (see Fig. 19) 
through which direct communication may take place between the uterus 
and the bladder. This may occur as an accident in midwifery practice, 
constituting a vesico-uterine fistula, as in a case reported by the writer. 1 
From the front to the back of the uterus, the membrane now passes 
over the fundus, and investing the whole of the posterior surface with 
the exception of the vaginal portion, reaches downwards behind the 
vagina, in the manner already described, to form the pouch of Douglas. 
The manner in which the uterus is thus embraced by the peritoneum in 
its course from before backwards is peculiar. Instead of investing the 
lateral parts of the organ in the same manner as the anterior and 
posterior walls, it is stretched from side to side of the pelvis, forming, 
in fact, a double layer of peritoneum, in the centre of which the uterus 
is confined. These folds, intimately connected on either side with 

1 Glasgow Medical Journal, 1862. 



III.] 



RELATIVE POSITION OF PELVIC ORGANS. 



63 



important organs to be presently described, are the broad ligaments of 
the uterus. 

Looking from above downwards in the axis of the brim, it will be 
noticed that the broad ligaments, with the uterus, u } form a partition or 









Fig. 27. 







Pelvic organs in silu, viewed in the axis of the hrim. (After Schultze.) 

curtain, dividing the cavity of the pelvis into two parts, anterior and 
posterior, of which the anterior is occupied mainly by the bladder, b, 

Fig. 28. 




Anterior view of the uterus and its appendages. (Quain.) 

and the pouch which separates it from the womb, and the posterior by 
the rectum, r, and the pouch of Douglas. It will also be observed 



64 



FEMALE ORGANS OF GENERATION. 



[CHAP. 



that the greater convexity, and, indeed, the bulk of the uterus, projects 
into the posterior of the two cavities. The attachment of the broad 
ligament is in point of fact to the anterior lip of the lateral border of 
the womb. 

If, therefore, the uterus and the broad ligament are viewed from 
before, as in Fig. 28, the fundus and body of the uterus are indeed 
indicated, as well as the situation of other parts to be mentioned im- 
mediately, and the relation which they all bear to the vagina ; but the 
parts themselves are only to be distinctly demonstrated by turning our 
attention to the posterior surface of the pelvic partition, as shown in 
Fig. 29, where the posterior wall of the uterus has been removed, in 

Fig. 29. 




Posterior view of the uterus and its appendages. (Quain.) 



order to show the interior of the organ. The peculiar structure of the 
cavity of the cervix, the anterior lip of the os, and the anterior wall of 
the vagina are also shown, as also the triangular space bounded infe- 
riorly by the ovary and its ligaments, which, from a fanciful resem- 
blance to a bat's wing, has been called ala vespertilionis. 

It is thus very apparent that the effect of the broad ligament is to 
maintain the uterus in its central position as regards the pelvic cavity, 
and to prevent its displacement downwards, while it admits of very 
free antero-posterior movement, corresponding to the distension of the 
bladder or rectum. 

Between the two layers which constitute the broad ligament, and 
occupying each a fold more or less distinct, are the following structures : 
the round ligament (see Fig. 27), a cord-like bundle of fibres, partly 
muscular, and about four and a half to five inches in length, which has 
its course on each side from the angle of the uterus, first upwards and 
outwards, and then forwards and a little inwards to the internal ingui- 
nal ring. Passing, like the spermatic cord in the male, through the 
inguinal canal, and invested by a peritoneal sheath called the canal of 
Nuck, its fibres expand and are lost in the mons veneris, some of them 
having been traced to the purse-shaped cavity in the labia majora 
already described. According to Madame Boivin, the ligament of the 
right side is a little shorter and thicker than the other. Two small 



III.] LIGAMENTS OF UTERUS. 65 

semilunar folds are seen on this aspect, which are formed by the peri- 
toneum in its passage from the uterus to the bladder, and which limit 
laterally the pouch existing between these two organs. They are called 
the vesico-uterine ligaments. The uterus is generally observed to be a 
little more to the right than to the left side ; and it is asserted by 
Schultze that in the normal position it is somewhat twisted on its axis, 
so as to turn the anterior surface a little to the right. On this obser- 
vation is grounded a theory which Schultze has propounded as to the 
position of the child in the womb. All this is shown in Fig. 27. 

Reverting now to the posterior surface of the broad ligament, we 
find several parts which are of the highest physiological importance. 
At the upper or free margin of the broad ligament, and occupying a 
portion of the space between its layers, there extends from each angle 
of the uterus a thick cord, between three and four inches in length, at 
first nearly straight in its direction, but in its outer half pursuing a 
somewhat tortuous course, especially in young subjects. This is found, 
on dissection, to be traversed in its whole extent by a canal of small 
diameter, and is familiarly known to anatomists as the Fallopian tube 
[oviduct). It is composed in a great measure of muscular tissue of the 
non-striated variety, which is disposed in layers, an external one of 
longitudinal, and an internal of circular fibres. Along with this is 
areolar tissue, the whole being embraced by the peritoneum in the 
manner described. The canal is lined with mucous membrane, with 
an epithelium of the columnar and ciliated variety, continuous at one 
extremity with the mucous membrane of the uterus, and at the other 
with the inner surface of the peritoneum — a unique example of a mu- 
cous being continuous with a serous membrane, and of a serous cavity 
which is not absolutely a closed sac. The tube is small, and its cavity 
narrow at the uterine end, barely permitting the passage of an ordinary 
bristle, but it becomes dilated in its course outwards, and ultimately 
expands into the trumpet-shaped extremity from which it derives its 
name {tuba). The mucous membrane lining the canal is disposed in 
longitudinal folds, so that in a transverse section of the structure the 
cavity presents a stellated appearance. The mouth of the tube has a 
very irregular and fringed margin, hence its name of fimbriated ex- 
tremity — the fimbria? being arranged in a circular manner, and sur- 
rounding the orifice, which looks downwards in the direction of the 
ovary. With this organ it is in fact connected by the elongation of 
one of the fimbria?. When the ovum comes to maturity within the 
ovary, that portion of the organ from which it is about to escape by 
dehiscence is firmly grasped by the fimbria? (morsus diaboli), and the 
ovum is received into the oviduct, and by it conducted to the uterus, 
where it is retained and developed, or whence it is discharged, according 
to circumstances. 

Leading from the inner extremity of the ovary — an organ to be 
hereafter described — is a dense cord, composed mainly of fibro-areolar 
tissue, but containing also muscular fibres. This is the ligament of the 
ovary, which is also, like the round ligament and the Fallopian tube, 
firmly united to the angle of the uterus at a point behind and below 
the latter, and is about an inch and a half in length. The parovarium, 

5 



66 FEMALE ORGANS OF GENERATION. [CHAP. 

or organ of Rosenmiiller (Fig. 30, p o), is situated between the layers 
of the broad ligament, and can usually be brought into view by holding 
up to the light that portion of the ligament which is between the outer 
part of the ovary and the Fallopian tube. According to the observa- 



FlG 




Diagrammatic view of the uterus and its appendages as seen from behind. (Quain.) 

tions of Kobelt and Follin, the parovarium is usually composed of from 
seven to ten tubules, which are convoluted and end in a cul-de-sac, all 
converging towards the tube through which the vessels of the ovary 
pass. These tubes exist at all ages, but are more distinct in children, 
and still more so in the foetus. In no instance have they been found 
to have an orifice, but there seems good reason to believe that they 
correspond to the epididymis of the male, more especially the coni 
vasculosi, and are therefore the vestiges of the upper part of the 
Wolffian bodies of the embryo. It is more than likely that the little 
cysts so frequently found in this situation, which are usually pedicu- 
lated, have some anatomical connection with the parovarium. From 
the back of the uterus on each side, crescentic folds of peritoneum pass 
backwards towards the rectum (Fig. 27). They are more marked 
than the vesico-uterine folds, previously described, and are called the 
posterior or recto-uterine ligaments, or folds of Douglas, as they mark 
the upper boundary of the pouch with which the name of this anato- 
mist is associated. 

That muscular fibres exist between the layers of the broad ligament 
is a question no longer open to doubt ; and there seems good reason to 
believe, from the researches of Rouget and others, that this is only a 
portion of a continuous envelope of muscular fibres, embracing the 
uterus, Fallopian tubes, and ovaries. These fibres are believed to 
exercise an important physiological function, in bringing all the struc- 
tures into harmonious action, and more especially in insuring the pre- 
cision with which the fimbriated extremities of the Fallopian tubes 
grasp the ovaries. 

The uterus is thus — by means of its ligaments and other auxiliary 
structures — so suspended in the cavity of the true pelvis as to admit, as 
has been shown, of tolerably free movement ; and, at the same time, to 



IV.] MUCOUS MEMBRANE OF UTERUS. 67 

restrict its mobility within certain limits. The movement of the body 
from side to side is curtailed effectively in a healthy state of the parts, 
by the broad ligament, while displacement backwards is prevented by 
the vesico-uterine folds and the round ligament, and movement in the 
contrary direction by the recto-uterine ligaments. Undue importance 
must not, however, be attached to the function of these structures as 
ligaments ; for it is very obvious that other parts (and in an especial 
degree the vagina) aid them in holding the uterus thus in suspension. 
The general laxity of all these tissues, however, which nature permits 
in view of the higher function of the uterus, is very apt, under disturb- 
ing influences, to give rise to displacements which have already been 
named, but the consideration of which belongs more properly to the 
department of gynaecology. It may, however, be observed that the 
symptoms of these displacements are, in a great measure, mechanical, 
and the direct result of the loss of equilibrium — as those, for example, 
which arise from pressure on the bladder or rectum, and the pain in 
the groin frequently experienced in retroversion, which is assumed by 
Cazeaux to arise from tension of the round ligament. 

In the interval between the two layers of the broad ligament, and 
associated with the other structures above described, there is found a 
considerable quantity of loose and extensible cellular tissue. This 
admits of the complete alteration in the anatomical relations of the parts 
which occurs during pregnancy, and which is further provided for by 
the manner in which the uterus is attached to its serous investment. 
The nature of the connection is firm at the fundus, and lax at the sides, 
where the peritoneum may be moved by the finger to and fro upon 
the subjacent tissue of the organ. The manner in which the neigh- 
boring parts accommodate themselves to the distension of the womb 
during pregnancy will fall to be considered in a subsequent chapter. 



CHAPTER IV. 

FEMALE OKGANS OF GENEKATIO^ (Continued). 

OF THE PROPER TISSUE OF THE UTERUS — OF THE MUCOUS LAYER ; ITS STRUC- 
TURE AND GLANDS, IN THE BODY AND CERVIX — BLOODVESSELS OF THE 
UTERUS — LYMPHATICS AND NERVES — MALFORMATIONS AND ABNORMAL CON- 
DITIONS — THE OVARIES : THEIR STRUCTURE — THE GRAAFIAN VESICLES AND 
THEIR DEVELOPMENT — THE OVUM— PHENOMENA OF OVULATION — FORMATION 
OF THE CORPUS LUTEUM — THE CORPUS LUTEUM OF PREGNANCY DISTIN- 
GUISHED. 

The Proper Tissue, which lies immediately beneath the peritoneum, 
and which constitutes the greater part of the walls of the uterus, is very 
dense in structure, and, except during pregnancy or a menstrual period, 
is of a grayish color in section, and displays numerous bloodvessels, 



68 FEMALE ORGANS OF GENERATION. [CHAP. 

some of them of considerable size. It is thickest at the middle of the 
body and at the fundus, thinnest at the Fallopian tubes, and is com- 
posed throughout of bundles of muscular fibres of the plain variety. 
These fibres in the unimpregnated condition are interlaced, disposed 
very irregularly in bands and layers, and mixed with fibro-areolar tissue, 
which is more abundant near the external surface. As in the case of 
other hollow viscera, the muscular elements may be described as con- 
sisting of an external layer, the fibres of which have a general longi- 
tudinal direction, and of an internal or circular layer. From the 
irregular manner, however, in which, in the unimpregnated uterus, the 
bundles of fibres are disposed, and the intimate union which subsists 
between them, this seems on the first glance to be somewhat of a forced 
analogy. And it would probably remain so, were it not that during 
pregnancy the stratification of the muscular tissue becomes much more 
distinct, so as to render the comparison quite justifiable, a fact which 
will be brought out more clearly afterwards. Anatomists usually 
divide this tissue into three layers, external, intermediate, and internal. 
3fucous Membrane. — The very existence of this membrane was long 
disputed, the obvious reason being that it differs so much from other 
mucous membranes, that physiologists, with some show of reason, 
refused to admit the analogy. More modern and more exact observa- 
tions, however, leave no doubt in these days as to the propriety of 
classifying it as it is here named. The descriptions which are usually 
given of this membrane by anatomists are very meagre, and in some 
respects inaccurate; this may serve as our warrant for examining its 
structure and functions a little more in detail than under other circum- 
stances might have been necessary. Although often described as a thin 
membrane, it is, on the contrary, probably the thickest mucous mem- 
brane in the body, constituting, according to M. Coste, in the cavity, 
about one-fourth of the entire thickness of the organ. In this situation, 
it is of a reddish tint, but in the cervix, where it is much thinner, it is 
paler in color, the thinning occurred somewhat abruptly at the os inter- 
num. It is firmly adherent to the subjacent muscular tissues, and can- 
not, in consequence of the sparseness of the submucous cellular tissue, 
be made to glide upon the part which it covers. The surface of the mem- 
brane is smooth, and abundantly studded over with minute dots, which 
are found on closer examination to be the orifices of numerous utricular 
glands, which run through the entire thickness of the membrane in a 
direction perpendicular to its surface. Fig. 31 represents a part of the 
cavity of the uterus which shows in section — a, the orifices of the glands, 
and d, the glands themselves. They were believed by Weber, and 
are here represented, as being, at the commencement of pregnancy, 
greatly convoluted, and sometimes bifurcated at the extremities. The 
more recent and exact observations of M. Robin show, however, that 
when in situ, they are rather undulated than convoluted, that they 
are never spiral, although, as in Fig. 32, they may appear so when 
separated, and never bifurcating. During pregnancy and menstruation, 
they become greatly enlarged, and sometimes cross each other, an ap- 
pearance which in all probability has led to the idea of a division of 
the tube. They are simple utricular glands, parallel to each other, 



IV.] 



MUCOUS MEMBRANE OF UTERUS. 



69 



ending in a cul-de-sac, and permeating the entire membrane. They 
are lined by nucleated ovoid epithelial cells, their walls being finely 
granular, and very firmly adherent to the tissue which intervenes 
between them. Their length measures exactly the thickness of the 



JSmm 



Fig. 31. 

MB 




>MM,&kt?$ 



mnmmw^^- 



l 



Utricular glands of uterus. (E. H. Weber.) 



mucous membrane, and is least, therefore, where the' membrane be- 
comes thinner, on its approach to the os internum and the orifice of the 
Fallopian tubes. " If we except that of the stomach/' says M. Robin, 1 



Fig. 32. 



Fig. 




Utricular gland of the 
uterus. (Coste.) 




Relation of utricular glands to muscular 
tissue of uterus. (Coste.) 



" there is no mucous membrane more rich in glandular follicles than 
that of the uterus." In the pig and some other animals the epithelial 
cells which line the glands are ciliated. 

In the unimpregnated uterus, in an intermenstrual period, the utric- 
ular glands are not very easily seen ; but if their sections are treated 
with acetic acid or concentrated tartaric acid, and viewed by transmit- 
ted light, they can generally be made out. They terminate quite 
abruptly at the inner margin of the muscular coat, the point of junc- 
tion being very distinctly indicated by the muscular fibres running at 
right angles with the tubes. The glands were supposed by Sharpey 
to penetrate the muscular tissue, but this view is now generally re- 
garded as an erroneous one. Their abrupt termination is well shown 
by a reference to Fig. 33. In the same preparation, which was taken 



De la Muqueuse Uterine. Paris, 1861. 



70 



FEMALE ORGANS OF GENERATION. 



[CHAP. 



from the uterus of a young girl who had committed suicide in the 
intermenstrual period, is also shown the general direction of the fibres 
composing the proper tissue of the uterus, p, as compared with the 
course of the tubules from the free surface of the mucous membrane at 
m. At a the tubes are cut across, and shown obliquely in section, and 
the course of the bloodvessels which accompany them is also indicated 
between m and the adjacent part of the muscular tissue. 

Fig. 34, also taken from Coste's beautiful plates, shows a detached 
portion of the mucous membrane in the same case. Little funnel- 
shaped depressions are shown at a, into which the orifices of the tubes 
open. The actual glandular orifices are distinctly shown elsewhere on 
the surface of the membrane. From one portion, the epithelium has 
been stripped off, so as to show the termination of the tubes free and 
floating. But what is most distinctly shown here, is the perfect net- 
work of vessels which surrounds the orifices, which is always to be 
observed most distinctly at those seasons when the functional activity 
of the uterus is excited. 

Fig. 35 is a small portion of the mucous membrane as observed after 
recent impregnation. This specimen is represented as viewed upon a 



Fig. 34. 



Fig. 35. 





Termination of utricular glands on 
mucous surface of uterus. 



Utricular orifices of 
uterus. (Sharpey.) 



dark ground, and also shows the orifices of the uterine glands, in most 
of which, as at 1, the epithelium remains, and in some, as at 2, it has 
been lost. 

The mucous membrane is smooth on its surface, which is composed 
of columnar and ciliated epithelium. Cruveilhier describes it, how- 
ever, as presenting indistinct papillae, while some earlier physiologists 
insist that it is studded with free villi : errors which have probably 
had their origin, as M. Robin assumes, in the extremities of the gland- 
ular follicles becoming liberated from their epithelial attachment by 
post-mortem change, and which find in analogy an apparent corrobora- 
tion in the condition of the membrane as observed in the uterine 
cornua of some mammalia. During pregnancy, the epithelium becomes 
transformed ; it loses all trace of the vibratile cilia, and the cells are 
changed from the columnar to the pavement variety. 



IV.] BLOODVESSELS OF UTERUS. 71 

Berres 1 was the author of the erroneous hypothesis that the villi of 
the placenta plunged into these glands to be there bathed in materials 
destined for the foetal blood, a view which was afterwards supported by 
Bischoif, 2 but which now receives little if any support. M. Coste 3 was 
undoubtedly the first who gave a complete description of the mucous 
membrane during menstruation and the various stages of pregnancy. 
To him the merit is also due of having first demonstrated, what is now 
all but universally admitted, that the maternal covering of the ovum 
(decidua), of which we shall have more to say, is not a new formation, 
as Hunter taught, but is the mucous membrane itself, altered and 
modified to suit the circumstances of the case. The views of Coste have 
received the most remarkable confirmation by the subsequent observa- 
tions of Richard, and by the still more recent researches of Robin. 

The mucous membrane of the uterine cavity is continuous at the 
angles with that which lines the Fallopian tubes. At the internal os, 
it becomes much thinner, with fewer glands, and loses many of its 
special characteristics as it passes into the cavity of the cervix. The 
presence of the folds, which give to it in this situation an arborescent 
appearance, has already been noticed. The extent of the inner surface 
of the cervix is thus greatly increased, an arrangement which not only 
admits of free dilatation of the parts, but also furnishes a greatly in- 
creased secretory surface. It has been computed by Dr. Tyler Smith 
that, in a well-developed virgin uterus, the follicles of the cervix 
(gJandulce NabotJd) are not less in number than ten thousand. These 
glands secrete a clear tenacious fluid, which is alkaline in reaction, and 
which is often seen on vaginal examination to occupy the os externum, 
and they are liable during pregnancy to a very remarkable hypertro- 
phy. The mucus which lubricates the parts during delivery is mainly 
derived from this source, and in certain morbid conditions it is greatly 
increased in quantity, when it is either secreted of an acid reaction, or 
loses its alkalinity, and also its transparency, by contact with the acid 
mucus of the vagina. The cavity of the cervix is lined with an epithe- 
lium which in its lower half is squamous like that of the vagina. 
About midway between the outer and inner os, it assumes the charac- 
teristics of the ciliated and columnar epithelium of the cavity. 

The uterus is supplied with blood from two sources. The ovarian 
arteries have their origin, like the spermatic in the male, from the 
aorta, at a point a little below the renal arteries. Passing over the 
psoas muscles, and occupying a fold in the peritoneum, which is indi- 
cated in Fig. 27, they pass between the layers of the broad ligament — 
forming what have been described as the ovario-pelvic ligaments. 
They follow, in their passage towards the ovary, an extremely tortuous 
course, which admits of free distension during pregnancy without any 
risk of diminution of their calibre. Giving off branches to the ovary 
and round ligament, they now pass inwards to join the uterine arteries 
on each side. These latter spring from the interior division of the in- 



1 Medicinische Jahrbiicher des K. K. (Esterreich. Staates. Wien, 183^ 

2 Traite du developpement de l'homme, etc., 1845. 

3 Histoire du developpement des Corps Organises. Paris, 1847. 



72 FEMALE ORGANS OF GENERATION. [CHAP. 

ternal iliac, pass between the layers of the broad ligament downwards 
towards the neck of the uterus, then upwards, pursuing, like the 
ovarian arteries, a very tortuous course, and, giving off numerous 
branches to the uterus, effect a union with the ovarian. Frequent 
anastomoses take place, and the branches may be seen to lie in little 
canals or channels on the surface of the womb, before they penetrate 
more deeply. The veins correspond to the arteries just named, and 
are of considerable size. They form plexuses, which communicate 
freely, and during pregnancy their calibre becomes enormously in- 
creased. Within the substance of the uterus, the ramifications of the 
arteries retain their spiral form, but become straighter as they approach 
the mucous membrane, where fine branches surround the utricular 
glands, and ultimately form, as has been shown (Fig. 34), a fine net- 
work on the free surface of the membrane. The veins which convey 
the returning current are, at their origin, of small size, but become 
much larger within the substance of the womb, attaining during preg- 
nancy a size so considerable that they are designated the uterine sinuses. 
The cervix is very much less vascular than the body and fundus. 

Numerous lymphatics, which are fully developed only during preg- 
nancy, have been traced to the uterus. Some doubt still exists, how- 
ever, as to the precise source of the nervous supply. All agree that the 
chief supply is from the sympathetic system, — the hypogastric, renal, 
and inferior aortic plexuses being all believed to contribute. An idea 
generally entertained is, that the sacral nerves send some filaments to 
the cervix, but this has been denied by Dr. Snow Beck, 1 who failed in 
his dissections to discover any single filament proceeding from this 
source. M. Jobert has asserted, again, that no nerves whatever are 
sent to the vaginal portion of the cervix ; but this has been warmly 
refuted by M. Boulard. There can be no doubt that the presence in 
the cervix of filaments from a cerebrospinal source, or the absence 
from its vaginal portion of all nerves whatever, are both observations 
which, if confirmed, would tend to throw some light on certain phys- 
iological and pathological facts. 

While, as a rule, in the Mammalia, the vagina is single, the contrary 
is the case as regards the womb. In the female human embryo, the 
uterus is formed by the median fusion of the lower parts of the ducts 
of M tiller — which are the efferent tubes of the rudimentary generative 
apparatus. These meet together inferiorly, become gradually united 
from below upwards, and ultimately form a single cavity by the ab- 
sorption of the partition between the two, so that there is a stage in 
development, at which the human uterus is composed of two separate 
and distinct tubes. It follows, from the manner in which they become 
united, that there is a series of subsequent stages at which the partly 
developed organ may be termed uterus bicollis — when the necks are 
still separate; bieorporeus — when the union has reached the os inter- 
num; bifundalis — when the fundus alone is divided; biangularis ; 
and, finally, the uterus simplex — the highest or perfect human form. 
In the other Mammalia, the process is so far identical, but may be 

1 Philosophical Transactions, 1846. Part II, p. 219. 



IV.] UTERINE MALFORMATIONS. 73 

arrested at any stage to form the uterus natural to the group to which 
the individual belongs. In the Marsupials, not only are the uteri 
separate, but also the vaginas. In a large number of the Rodents, the 
vagina is single, and into its fundus two distinct uterine cavities open 
by separate apertures ; while, in some, there is a partial separation of 
the vagina for about a third of its length. The commencing union of 
the cervix is shown in some groups of the same order — as the MuridaB 
— where there is a very short common cavity. The confounding of 
the two uterine cavities may be traced in various progressive stages by 
an examination of the internal organs of certain of the Carnivora, the 
Ruminants, the Ungulata, the Edentata, and the Simiina ; but even in 
women there still remains in the angles of the uterus a trace of the 
original bifurcation. 

This reference to the development of these parts, and, for the analogy, 
to their condition in the lower animals, will be found to throw light 
upon certain cases of malformation or peculiarity of structure in the 
human subject, which apparently consist, for the most part, of a simple 
arrest of development. Taking the particulars above noted as a basis 
of classification, we may adopt the division in regard to those abnor- 
malities which Dr. A. Farre, in his essay on the uterus, 1 has selected 
as the best. Of this section of his admirable monograph, the following 
remarks are in great part an abstract. 

Group 1. Complete absence of the uterus, both of the ducts of 
Miiller being imperfect or undeveloped. In the cases of total absence 
of uterus which have been recorded, it seems certain that, in a very 
large proportion at least, something of a rudimentary organ existed in 
the fold of the peritoneum lying behind the bladder, and representing 
the broad ligament. They usually occur under the form of two hollow 
rounded cords, or bands of uterine tissue, extending upwards towards 
the ovaries. The vagina may be absent or rudimentary, as also the 
Fallopian tubes ; but it is interesting to observe that the ovaries may 
be perfect in these cases — a fact easy of explanation, when we remem- 
ber that the ovary is formed out of a separate portion of blastema from 
the Wolffian bodies and duct of Miiller. 

Group 2. One uterine cornu only may retain the imperfect condition 
last described, while the second develops, so that we now have what 
has been called the uterus unicornis. In this condition, which repre- 
sents the type of the normal condition in birds, both ovaries may be 
found perfectly developed. 

Group 3. When development progresses in both cofnua, and these 
do not, as under ordinary circumstances, unite, various peculiarities 
result, which cause the uterus to assume, according to the degree of the 
malformation, a type which is lower or higher in the animal scale. 
" The marsupial type/' says Owen, " is repeated in one of the rarer 
anomalies of the female organs in the human species." This, indeed, 
is an anomaly so rare and peculiar, that it has only been observed as 
coexistent with other malformations, — such as fissure of the abdomi- 
nal and pelvic walls ; but what is more frequently met with is the form 

1 " Cyclopaedia of Anatomy and Physiol ogy." Art. " Uterus." 1859. 



74 



FEMALE ORGANS OF GENERATION. 



[CHAP, 



shown in Fig. 36, where the two uterine halves meet, and are united 
by a commissure of true uterine tissue, which represents the fundus 
uteri. The higher this commissure reaches, the more does the womb 
approach to the normal type. In the figure there are two vagi me, two 
orifices, and two uterine cavities. 

In the case shown in Fig. 37, there is but one vagina. The os also 
is single, as is the cavity of the cervix, the bifurcation commencing 



Fig. 36. 



Fig. 37. 




Double vagina and uterus. (After Busch.) 



Bifid uterus. 



about the os internum. The angle at which the cornua unite varies in 
different cases — which is accounted for, as is pointed out by Rokitansky, 
by the height at which the uniting commissure is situated. 

Group 4. In this, the external form of the uterus differs but little 
from the normal character. The breadth of the organ is greater, es- 
pecially at the fundus, where a depression in the middle line indicates 
the situation internally of a vertical septum, which more or less com- 
pletely divides the uterine cavity into two halves, and constitutes the 
uterus biloGularis. The extent of this septum may vary from a mere 
ridge to a complete partition, which may even invade the vagina. 

These several deviations from the normal form of the uterus will 
influence more or less the function of the organ. Menstruation may, 
it is true, in a large proportion of cases, be scarcely affected ; and this 
function will be normally discharged whenever the ovaries are perfect 
and a normal channel exists. In those rarer cases, however, in which 
the uterus is rudimentary, there may be perfect ovaries, and atresia 
either of the cervix or of the vagina, with the result, if a uterine cavity 
exists, of an accumulation of the discharge, and attendant symptoms of 
considerable severity. If, on the contrary, there be no cavity, the 
menstrual molimen may then be relieved by the occurrence of vicarious 
discharges. As regards the influence exercised by such anomalies 
upon impregnation, much will depend upon the condition of the 
vagina, and also of the Fallopian tube, for if either of them are 
closed, impregnation is of course impossible. If, however, they are 



IV.] THE OVARIES. 75 

open, it is quite possible for impregnation to occur even in a uterus 
unicornis. 1 

Great difficulty and danger may arise, in such cases, during the prog- 
ress of gestation. In the case, for example, which is referred to in the 
footnote, death took place from rupture of the sac in the third month, 
the termination being thus very much what one would expect in a case 
in which the development of the ovum goes on in the Fallopian tube, 
instead of in the cavity of the womb. In the cases of the uterus 
bicornis and bilocularis, either side of the uterus may become separately 
or alternately the seat of gestation, or twins may be simultaneously 
developed, one on each side. There is, indeed, no good anatomical 
ground for absolutely rejecting the doctrine of superfoetation as a possi- 
bility in such cases. When there is a double vagina, coition usually 
takes place by one canal, so that successive pregnancies may be looked 
for on the same side. The effects produced on the act of parturition 
by such anomalies as have been cited, have probably been exaggerated. 
Rokitansky has indeed shown that the axis of expulsion may, as in the 
one-horned variety, be so directed as to place the forces at an obvious 
disadvantage; but it may be assumed that, if the anomaly has been 
of such a grade as to admit of complete intra-uterine development, 
there will not likely be any impediment during delivery, which may 
not be surmounted by the application of ordinary principles. 

Cases in which the arrest of development has taken place after birth, 
are to be placed in a special category. At the ordinary period of 
puberty, the signs which indicate sexual maturity do not appear, 
while the uterus is found still to present the characters peculiar to 
infancy or childhood. In these cases, which are almost certainly pro- 
ductive of sterile marriages, there is often an absence of the vaginal 
portion of the cervix ; and the other infantine conditions of the womb 
may be exhibited in every particular, such as the exaggeration of the 
forward curve, which, in a smaller degree, we have indicated as the 
normal adult condition, the persistence, within the cavity, of ruga?, 
similar to those of the cervix, and the thinness of the parietes. 

Of the Ovaries. — Projecting on either side from the posterior surface 
of the broad ligament, and invested with a special fold of its posterior 
layer, are the important organs within which is elaborated that which 
the woman contributes to the propagation of her species, analogous 
therefore in this, as in other respects, to the testicles of the male. They 
are connected (see Figs. 27, 28, and 29) with the uterus by a special 
ligament already described, and also through the Fallopian tubes, to 
one of the fimbriae of which they are permanently adherent. In shape, 
the ovary is a flattened oval. It varies greatly in size, according to 
age, and in different individuals of a similar age; but it may be set 
down as, on an average, about eighty grains in weight, and* an inch 
and a half in extreme length. From the manner in which it is em- 
braced by the peritoneum, it is free on two sides, and on the posterior 
border, and attached to the broad ligament by a kind of mesentery 

1 See a remarkable case by Kokitansky, the preparation of which is in the Vienna 
Museum. (Pathological Anatomy — Syd. Soc, vol. ii, p. 277.) 



76 FEMALE ORGANS OF GENERATION. [CHAP. 

along the anterior border only, where, between the layers, the vessels 
and nerves enter. The nature of the relation subsisting between the 
ovary and the peritoneum has of late been a subject of much interest to 
physiologists, and the observations of Waldeyer 1 certainly now leave 
no room for doubt that anatomists have been in error in describing the 
ovary as invested by the peritoneum in the same manner as the other 
viscera. The structure of the peritoneum proper ceases abruptly at a 
fold near the hilus, and quite visible to the naked eye. This fold 
surrounds the ovary in such a way that the greater portion of its free 
surface consists, not of the peritoneum, but of a special layer, continuous 
with the peritoneum, presenting, on microscopic examination, a pris- 
matic epithelium instead of the laminated form which exists in the 
serous membranes. This prismatic epithelium is intimately connected 
with the origin of the ova. The ovary attains its greatest size after 
puberty, and is, up to this period, smooth on the surface. During 
pregnancy, the position of the organ is completely changed ; but in the 
unimpregnated condition it will be found lying deeply in the lateral 
posterior part of the pelvic cavity, covered by the small intestines, and 
to some extent by the Fallopian tube of the same side. Beneath the 
outer covering, a dense layer of the stroma, somewhat white in color 
from a sparseness of bloodvessels, binds the proper structure of the 
organ together, giving support and protection to it, and to the impor- 
tant structures which it contains; this is the tunica albuginea. The 
bulk of the organ beneath this is composed of highly vascular tissue of 
a pinkish color, which is called the stroma of the ovary. The stroma 
is composed of a dense fibro-nuclear tissue, through which bloodvessels 
ramify from the base of the ovary towards its surface. 

The Graafian Vesicles. — If a longitudinal section is made through a 
mature and healthy ovary, these vesicles are brought into view, im- 
bedded in the stroma and varying considerably in size. In number 
and in situation, they differ greatly according to age. In infants and 
young children, the ovary is found to be composed, within the tunica 
albuginea, of two distinct portions, — one internal, corresponding to the 
stroma in the mature organ, and the other external, of considerable 
thickness and density. It is in the latter, or peripheral portion alone, 
that, at this time, the Graafian vesicles are to be found, in enormous 
numbers, but as yet of small size and in a rudimentary condition. As 
puberty approaches the distinction between the peripheral and central 
portion of the stroma becomes gradually less marked. Some of the 
vesicles enlarge and, according to Schron, retreat in the first instance 
towards the centre of the ovary. When puberty is attained, a certain 
number of them enlarge, and those which have attained the greatest 
size approach the surface. A few of them are from ^th to £th of an 
inch in diameter, or even more; but the great majority remain much 
smaller. Their number is also greatly diminished as compared with 
those existing in the ovaries of children, so that we may assume that a 
large proportion is absorbed. This number is still, however, very con- 
siderable, and has been computed by Henle at 36,000 in each ovary of 
a girl of eighteen. The ova, which are contained within these Graafian 

1 Eierstock und Ei. Leipzig, 1870. 



IV.] 



STRUCTURE OF GRAAFIAN VESICLE, 



77 



vesicles, being comparatively small, occupy in the case of the more 
developed vesicles a small space only, the rest of the vesicle being filled 
with fluid. Before puberty the ovaries are smooth on the surface, but 
they subsequently become scarred, wrinkled, and furrowed, in conse- 
quence of the share which they take — as we shall see immediately — in 
the phenomena of ovulation. 

The Graafian vesicle is usually described as consisting of two coats 
and a granular epithelial layer, three special coverings in all ; but in 
point of fact, there does not appear to be any distinct membrane lining 
the Graafian vesicle. This, indeed, is merely ovarian stroma in its 
finest form ; while, as regards the vascular layer usually described, its 
existence is more than doubtful, although in its developed state, a net- 
work of bloodvessels runs near the surface of the vesicle. 

The Ovum, in the mature condition of the Graafian vesicle, lies near 
its surface, and is imbedded in the membraria granulosa ; a layer of 
peculiar nucleated and granular cells, which surrounds the whole of 

FiCx. 38. 




Diagram showing the layers of the Graafian vesicle, and the contained ovum. 

the interior of the vesicle, and is thickened at that part where the ovum 
is imbedded in it (proligerous disk of V. Baer). This is shown in the 
accompanying diagram. 

If the surface of the ovary be punctured, while a mature Graafian 
vesicle is projecting, and the contents of the latter pressed out, a small 
spherical body may be observed, if care be taken, covered with granu- 
lar matter in greater or less quantity. It is more opaque than the 
medium in which it is suspended, and is remarkably constant in 
size — being about y-j-o^h of an inch in diameter. It is comprised of 
the following parts : 

a. A thick transparent envelope, which was called by Baer, the dis- 
tinguished discoverer of the ovum in the Mammalia, the Zona pellucida. 
As this refers only to its appearance, many physiologists prefer to call 
it the vitelline membrane, or membrane of the yolk. This membrane 
completely surrounds the ovum, and to all appearance is impervious. 
It presents at least no distinct aperture or micropyle such as is observed 
in some animals, and has been by some supposed to exist in the human 
ovum. 

b. The Yolk. — The cavity inclosed by the zona pellucida is filled 
with a substance, which is viscid and faintly granular, and which 



78 FEMALE ORGANS OF GENERATION. [CHAP. 

readily escapes when the sac is ruptured. It can scarcely be described 
as a fluid, as it retains its spherical form after rupture of the sac, and 
may, according to Bischoff, be broken into segments. It has no in- 
vesting membrane other than the zona pellucida. 

c. The Germinal Vesicle. — In the middle of the yolk, in the earliest 
stage, and in contact, in adults, with some part of the periphery of the 
investing membrane, a little vesicle is found, apparently, when seen in 
the more opaque medium in which it is suspended, quite transparent 
and colorless. This is the germinal vesicle — first described in the ova 
of birds by Purkinje, and discovered in the Mammalian ovum by 
Coste and by Wharton Jones. It is slightly oval, about 7 J()th of an 
inch in diameter, and surrounded by a very thin membrane. A more 
careful examination of it when removed from the yolk shows that it is 
not absolutely transparent, but contains a few scattered granules, and, 
in addition : 

d. The Germinal Spot of Wagner, which may be seen close to some 
point or other of the inner surface of the wall of the germinal vesicle. 
It is probably formed by the aggregation of cells and granules which 
give to it a greater opacity than characterizes the contents of the vesicle. 
It measures about jg'pth to o^pth of an inch. 

Although it is generally understood that the ovum is always to be 
found on the side of the vesicle next the surface of the ovary (Fig. 38), 
recent investigations have shown very clearly that this is by no means 
universal, and would almost seem to point to the conclusion that the 
contrary is the rule, and that, in the majority of Graafian vesicles, we 
are more likely to discover it on the side which lies towards the centre 
of the organ. 

The ova begin to be formed at a very early period, and are already 
to be found in great numbers in the superficial layer of the rudimentary 
stroma of the human ovary as early as the fourth month of intra-uterine 
life. But their first origin is even at an earlier period. The germinal 
vesicle is the part of the ovum first formed, and it appears to arise by 
involution from the superficial layer of germinal cells. One or more 
of these cells, becoming larger than the rest, sink into the stroma and 
soon become surrounded by a single layer of nucleated cells. This 
constitutes the commencement of the membrana granulosa, and repre- 
sents therefore the Graafian vesicle. As development proceeds, a small 
quantity of protoplastic yolk surrounds the germinal vesicle, and the 
cells of the membrana granulosa increase in number and assume more 
of the appearance of a cellular lining. The cells accumulate round the 
simple ovum so as to form the proligerous disk, and a space begins to 
be apparent between this and the rest of the membrana granulosa, 
within which the fluid of the vesicle afterwards accumulates. The 
ovum grows by the increase of the yolk round the germinal vesicle, 
the protoplasm becoming granular; and, finally, the yolk and germinal 
vesicle are inclosed by the external firm vesicular membrane, known 
as the zona pellucida. 

These, then, are the parts of which the mature ovum, prior to im- 
pregnation, consists. On the approach of puberty, as has been seen, 
several Graafian vesicles, each containing an ovum, approach the sur- 



IV.] PHENOMENA OF OVULATION. 79 

face of the ovary. As they increase in size, they form little projections 
beneath the investing membrane. In those animals where several ova 
are simultaneously fecundated — as in the sow (Fig. 40) — there may be 

Fig. 39. Fig. 40. 





Diagrammatic representation of the ovum, as it Development of Graafian vesicles 

escapes from the Graafian vesicle. in the sow. 

observed on the surface of the ovary a number of little cystic growths; 
but, in the human species, where the fecundation of more than one 
ovum at a time is exceptional, the Graafian vesicles, as a rule, come to 
maturity one by one, or in small numbers. 

The changes which take place during the maturation and discharge 
of the ova, and which are associated with the "rut" in many of the 
lower Mammalia, and with menstruation in women, constitute the 
phenomena of Ovulation. These changes are manifested, not only in 
the Graafian vesicle, but also in all the component parts of the internal 
generative system. 

It has already been observed that the development of the Graafian 
vesicle is due, in a great measure, to the increase in its fluid contents. 
While this is taking place, the vascularity is notably increased, not 
only in the vesicle itself, but in the contiguous portion of the ovary, 
and, in some degree, throughout the whole of the organ. The walls 
of the follicles become thickened, except at the part where rupture 
is about to take place, and a certain amount of blood is said to be 
effused into the cavity. This has frequently been observed (although 
even that has been disputed) in the sac of ruptured follicles ; but the 
researches of Pouchet — whose views are confirmed by Farre — seem to 
show that an actual sanguineous discharge may take place into the fol- 
licle, at a period prior to its rupture. According to Pouchet, the effect 
of this discharge is, mechanically, to force the ovum towards that part 
of the ovisac which is next the surface, — it being, before this, generally 
found on the deep or distal side. 

An increased vascularity is now observed, externally, over the salient 
portion of the vesicle, and the tissues become, about the centre of the 
projection, more and more thinned, until, at last, they yield — the ovum 
then escaping by a process analogous to dehiscence. The rupture takes 
place in a small spot where the bloodvessels previously are wanting. 
This is similar to the larger band of non-vascular tissue which exists in 
the ovicapsules of birds. Towards this non-vascular spot the neighbor- 
ing vessels converge in considerable numbers, causing the appearance 
we have just referred to. Assuming the theories above mentioned to 
be correct, the bursting of the vesicle is due, not merely to an augmen- 
tation of its fluid contents, but to a thickening of its internal layer, 



80 FEMALE ORGANS OF GENERATION. [CHAP. 

which becomes at the same time irregular in outline and yellowish in 
color; and also to an effusion of blood, which has been termed the 
menstruation of the follicle. 

This evolution of the ovum is accompanied by important changes in 
various parts besides the ovary. In so far as the uterus is concerned, 
these changes will come to be considered under menstruation. At 
present, it need only be observed that the Avhole of the internal genital 
organs become engorged. The Fallopian tube loses its pale color in- 
ternally, and often becomes of a violet hue from extreme congestion. 
This is more marked towards the fimbriated extremity, which com- 
pletely embraces that portion of the ovary where the mature vesicle is 
about to give way. The ovum is thus received into the Fallopian 
tube, but the rupture which admits of the dehiscence does not termi- 
nate the series of changes of which the ovary is the seat. 

Before attempting a description of these changes, however, we must 
consider for a moment the conditions under which rupture of the Graa- 
fian vesicle occurs, and the laws which determine this rupture. 

The celebrated experiments of Bischoff, as detailed in his well-known 
work, 1 have supplied most of the facts upon which, even at the present 
day, the conclusions of physiologists on this subject are based. From 
these, and from the corroborative results obtained by subsequent ob- 
servers, it is clear that ova may, in the Mammalia, as in animals lower 
in the scale, be discharged from the ovary independently of sexual in- 
tercourse, or of any kind of influence from the male. 2 In other words, 
sexual contact or excitement is not, as the earlier observers, down to 
Barry, believed, the one essential determining cause of the discharge of 
ova. From experiments on rabbits, which were conducted by Coste, 
it seems, however, more than probable that sexual congress may pre- 
cipitate a rupture which, but for the excitement, would have been de- 
layed. The immediate cause which leads to a rupture is thus somewhat 
obscure, but Ave recognize the fact that the occurrence is intimately 
associated with the maturation of the ovum, of which, in women, the 
periodic menstrual flow is the external manifestation. 

We have already seen that the internal layer of the Graafian vesicle 
presents a yellow color previous to its rupture, becomes wavy in out- 
line, and is very considerably thicker. This change of color has been 
shown by Farre to be due to the presence of very minute oil-granules, 
which give to the structure a yellow hue, — hence the name given to 
the follicle during the period of decline — the corpus luteum. After 
rupture, a laceration, fissure, or scar, marks, on the surface of the ovary, 
the spot whence the ovum escaped, and a longitudinal section, made 
through the ovary in this situation, will generally bring the yellow 
body into view. At first, its distinguishing characteristics are but 
faintly shown ; and it is this fact which caused Raciborski to assert 
that the corpus luteum was not found before rupture. Undoubtedly, 
however, the first stage of its formation is while the ovum is still 
within the vesicle; but it is only after rupture that the change in color 
becomes quite distinct, — a change w r hich Raciborski supposed to be due 

1 Beweis der von der Begattung unabhangigen periodischen Reifung und Loslo- 
sung der Eier, etc. 1844. 

2 See Raciborski " De la ponte period i que chez lafemmeetles Mammiferes." 1844. 



IV.] 



THE CORPUS LCIEUM. 



SI 



to an absorption of coloring matter from the blood-clot which fills the 
cavity. "Whether it is due in part to this, or wholly to a further de- 
velopment of oil-granules in the internal layer, as Coste supposed, the 
result is the yellow tint, which may be recognized from without, or. 
more distinctly, on sectiou. If the laceration has produced an opening 
of sufficient size, the clot which occupies the cavity may escape along 
with the ovum; but, if not, it is retained and absorbed. The folding of 
the internal layer now becomes much more distinct, so that the internal 
surface of the vesicle resembles cerebral convolutions on a minute 
scale. According to Coste, this plication is due in great measure to 
retraction of the external coat, but this does not seem by any means 
clear, seeing that the convolutions become quite as distinct in those 
cases where the diameter of the whole vesicle is not diminished. It is 
much more likely that the plication is mainly due to the rapid increase 
in the cells of the membrane, which, being confined within a limited 
space, is thus necessarily thrown into folds. In every case, the cavity 
of the vesicle becomes rapidly encroached upon, the furrows between 




Ovary dissected, to show the structure of the Graafian vesicle at various stages. (Coste.) 

the convolutions become deeper, and the result is that the follicle now 
presents, in a section, a stellated appearance, which is more or less 
marked according to the stage at which the corpus luteum has arrived. 
The various changes above alluded to are shown in Fig. 41. taken from 
(Teste's atlas, which represents an actual dissection, made at the Morgue, 
of the ovary of a young woman who had committed suicide towards 



82 



FEMALE ORGANS OF GENERATION. 



[CHAP. 



the end of a menstrual period. It must here be noted, however, that 
the most recent observations have failed to demonstrate the layers of 
the Graafian vesicle which Coste has so distinctly indicated. 

The ovary is partly dissected, to show the situation of the ova; and 
also the structure of the Graafian vesicles, and the changes which they 
undergo after rupture. Most of the vesicles are turgid, tending to pro- 
trude, and indicated by the network of vessels on their walls. Three 
of them are open. 

1. The vesicle to the left in the figure is intended to demonstrate the following 
peculiarities: 

g g. The granular membrane, which covers the whole internal surface of the 
Graafian vesicle. 
A thickened portion of this — granular disk — showing: 

o. The Ovum surrounded by the cells of the disk, and situated, as is usual, im- 
mediately before rupture, on the side next the peritoneum. 
i i. Internal layer of the Graafian vesicle, showing a rich vascular network, not 
only on the flaps which are turned back, but also in the interior of the 
vesicle, through the granular membrane. 
e e. External (vascular) layer, vascular like the former. 

2. The open Graafian vesicle in the centre of the figure has broken spontaneously 
at the point v, and has allowed its ovum to escape. The nipple-shaped part of the 
granular membrane, in which the ovum was imbedded, has escaped along with it. 

g. Layer of granular membrane, which has not been dragged out with the 

ovum. 
i. Internal layer of the Graafian vesicle, forming numerous folds, which are 

the earliest of the modifications through which this layer passes in the 

formation of the Corpus Luteum. 
e. External layer of the Graafian vesicle, retracted (sic Coste) on the former. 

3. The third Graafian vesicle, to the right, has been artificially pierced to show 
how the ovum, while escaping, drags with it that portion of the granular mem- 
brane in which it is lodged. 

g. Portion of the granular membrane, escaping by the opening made in the 

Graafian vesicle. 
ce. Ovum lodged in the thickened nipple-like projection of this membrane. 



Coste denies the presence, as a 



Fig. 42. 




Structure of the corpus luteum. (Coste.) 



rule, of a blood-clot within the 
Graafian vesicle. He asserts that 
the vesicle, after rupture, becomes 
filled with a gelatinous matter, 
which is slightly tinged with the 
coloring matter of the blood. This 
he shows in Fig. 42, where the 
ovary is divided in its whole 
length to exhibit the organization 
of the corpus luteum. The prep- 
aration was taken from a woman, 
the mother of several children, 
who died from poison a few days 
after menstruation. The body was 
exhumed and examined a week 
after death. No ovum was found 
in the uterus, nor in the Fallo- 
pian tube. An open corpus lu- 
teum, of considerable size, is shown 
in the lower part of the figure. 
a. Internal laver of the Graafian 



IV.] STRUCTURE OF CORPUS LUTEUM. 83 

vesicle, plicated and having commenced that hypertrophy which con- 
verts it into corpus luteum. 

b. Plastic semitransparent matter, which occupies the centre of the 
corpus luteum, adheres intimately to the internal surface of the con- 
volutions, and moulds itself upon them. To the right, this matter is 
left in its place ; on the left it has been detached, to show the subjacent 
convolutions and the impression which they leave upon it. 

c. An old corpus luteum, from a preceding menstruation, probably 
the one before last. 

Graafian vesicles — some intact, others open, and in various stages of 
development, are seen in other parts of the ovary. 

The description given, up to this point, applies to all corpora lutea, 
whether associated with pregnancy or not. It is therefore scarcely 
necessary to add that Haller was in error when he stated that " the 
corpus luteum is the effect of pregnancy alone. 77 The demonstration 
of this error caused many hastily to assume that the corpus luteum 
was, under no circumstances, a sign of pregnancy, and was, in conse- 
quence, of no medico-legal value — an unfortunate mistake, which has 
been productive of much confusion, as there certainly are points of 
difference which enable us, with care, to distinguish between the two 
varieties. 

The corpus luteum which is found when there has been no impreg- 
nation, runs something like the following course from the point at 
which we left it. It shrinks rapidly, the retractility of the outer coat 
being apparently the chief agent in its contraction. The contiguous 
surfaces of the convolutions become pressed together, and their free 
surfaces gradually approach across the cavity, so as rapidly to cause its 
obliteration. The vascularity of the vesicle, and of the stroma of the 
ovary, becomes notably diminished, the ovisac loses its yellow color, 
and becomes white — all these changes occurring in about twenty-five 
or thirty days, so that, on the approach of another menstrual period, 
the cavity is reduced to a comparatively small size. At this stage, its 
appearance, as represented in Fig. 43, a, is very characteristic, the rays 
which proceed outwards from the central cavity showing the point of 
junction of the convolutions. Several other vesicles are shown, of the 
ordinary size before enlargement. From this stage, the stellate re- 
mains of the vesicles gradually diminish in size, and retreat towards 
the centre of the stroma, to give place to others, until at last they are 
obliterated. Sometimes, they soften so rapidly, that they are com- 
pletely reabsorbed before the folds of the internal layer have actually 
come in contact or contracted adhesions. 

Widely different is the state of matters where the ovum has been 
impregnated. In this case, the functional activity of the uterus is, in 
a measure, shared by the ovaries, and manifests itself in an increased 
vascularity, which, instead of disappearing, as at the end of a menstrual 
period, is maintained, more or less, during the whole course of the 
pregnancy. It is, probably, in consequence of this, that the corpus 
luteum of pregnancy goes through a series of transformations, so much 
more elaborate, and extending over a period the duration of which is 
so much longer. Taking the duration of an unimpregnated follicle as 



84 



FEMALE ORGANS OE GENERATION. 



[CHAP, 



about two months to complete obliteration, the corpus luteum which 
accompanies pregnancy may be said to last usually for thirteen or 
fourteen months, while traces of it may be found at a still later period. 
Such a history involves the idea of special structure and modified 
development, and this a study of the facts amply corroborates. When 
pregnancy succeeds or accompanies the phenomena of ovulation, the 
earlier changes are the same as those already described; but instead of 
softening and rapidly shrinking, as in the former case, the inner coat, 
or ovisac, continues to develop in thickness, and deepens in color, in 



Fig. 43. 



Fig. 44. 





The corpus luteum of simple ovulation. 



Corpus luteum in the third month 
of pregnancy. (Montgomery.) 



consequence of an increase in the number of oil-granules in its sub- 
stance. There does not seem, in the first instance at least, to be any 
contraction whatever of the external membrane. On the contrary, 
there is some reason to believe that, at this stage, it often yields, so as 
to admit of an increase in the entire diameter of the vesicle, and, in- 
deed, if we admit Coste's description to be correct, when he describes 
the corpus luteum of pregnancy to be " as large as the ovary itself," 
this can only be accounted for in the manner described. The size of 
the ruptured follicle varies considerably, but it occupies, usually, during 
the first four months, about a fourth, a third, or a half of the entire 
ovary. During the period immediately succeeding impregnation, rapid 
hypertrophy of the inner coat goes on, and it becomes folded together 
into convolutions as before. The material being abundantly supplied, 
while the development still continues, causes the convolutions to be 
firmly pressed together, while their free surface encroaches upon the 
cavity. At the end of two months, the condensation of the hyper- 
trophied tissue of the ovisac will be found to have imparted to the 
follicle a considerable amount of solidity, which is quite obvious when 
it is pressed by the finger. Bloodvessels run through it, from the cir- 
cumference towards the centre, marking, probably, the situation of the 
original folds. These latter are no longer distinct, and are so com- 
pressed laterally that the layer has now the appearance of a very thick 
yellow coat surrounding the diminished cavity, which is up to this 
time, according to Montgomery, usually circular in form, as shown in 



IV.] 



THE CORPUS LUTEUM, 



85 



Fig. 44. The cavity here represented is, however, exceptional, and 
subject to much variety. 

The blood-clot which originally occupied the cavity, or, if we choose 
to adopt the view of Coste, the tinged lymph which is effused after 
rupture, undergoes certain metamorphoses, which ultimately result in 
the formation of a milk-white coat which lines the cavity, taking the 
place, as it were, of the original granular membrane. This membrane, 
which is also shown in Fig. 44, is fibrous in structure, and extremely 
tough. Occasionally, the cavity is obliterated at the fourth month, but 
generally it will still be found perfectly distinct, although much reduced 
in size, up to the sixth month of pregnancy (Fig. 45). The walls 
continue gradually to approach nearer to each other, the white lining 
membrane becomes thinner, and, folded into plaits, which, radiating 
outwards, are seen to intermingle with the yellow color of the ovisac. 
The outer boundary of the vesicle now becomes irregular in outline, 



Fig. 45. 





Corpus luteuni at the 
sixth month of preg- 
nancy. (Montgomery.) 



Corpus luteum at the period of 
delivery. 



and complete obliteration of the cavity ensues, a white stellated cicatrix 
in the midst of the yellow mass marking where its walls came into 
contact. This is shown in Fig. 46, the original drawing of which was 
taken by Montgomery from a woman who had died of inflammation 
of the uterus two days after mature delivery. Up to this time, and 
often for some weeks afterwards, numerous vessels radiate through the 
corpus luteum, as may be proved by injection. This vascularity is 
now markedly diminished, while, at the same time, the characteristic 
yellow color becomes fainter in hue. It is often not till four or five 
months have elapsed that all trace of the corpus luteum has disap- 
peared, a trace of the tough white membrane being then, it may be, 
still indicated by a very faint star-like scar in the stroma of the ovary. 
As the facts above set forth are of some medico-legal, as well as 
obstetric importance, they may be briefly summarized as follows : 



86 FEMALE ORQANS OF GENERATION. [CHAP. 

What is called the corpus luteura is due to a deposit of yellow fatty 
matter in, and hypertrophy of, the internal layer of the Graafian vesicle 
(ovisac). 

The formation of a corpus luteum always succeeds the rupture of a 
Graafian vesicle. 

Up to a certain point the changes in the Graafian vesicle are uniform, 
and have no relation to pregnancy. The corpus luteum of pregnancy 
may, however, be distinguished in its subsequent course, by its higher 
development and longer duration, its hardness, its vascularity, and, at 
a later stage, by the formation of the white lining membrane, and large 
central stellate cicatrix. 

The presence in the ovary of a corpus luteum is no evidence of preg- 
nancy, unless the characteristics last indicated are distinct and une- 
quivocal — under which circumstances it is a certain sign. 

With reference to the above conclusions, it may be remarked that 
much confusion has arisen from the employment loosely of the terms 
"true" and "false," as applied to the corpus luteum, in so far as they 
are assumed to imply a distinction, which proves or disproves the 
occurrence of pregnancy. " There is as little reason," says Farre, with 
justifiable emphasis, " for the use of the last term as there would be for 
denominating a child a false man. . . . These terms actually represent 
the same body, only in different stages of growth or decay." 

During the whole of the childbearing period of a woman's life, 
the ripening and dehiscence of the Graafian vesicles are of periodic 
occurrence. In those animals in which plural births are the rule, several 
vesicles ripen and discharge their contents at, or near, the same time ; 
but in man this is exceptional, and we thus find that one vesicle only, 
as a rule, ripens at a time, bursts, discharges its contents, and rapidly 
shrinks as it retires towards the centre of the ovary ; to give place in 
their turn, in a normal condition of the parts, to a constant succession 
of vesicles, which, one by one, run a similar course after discharging 
their ova. There is every reason to believe, further, that during preg- 
nancy and suckling, while the uterine functions are in abeyance, those 
also of the ovary are temporarily arrested, in so far as the development 
of new Graafian vesicles is concerned, — the whole generative force 
being, as it were, turned into other channels. 

The numerous lacerations which, in consequence of repeated ruptures, 
take place on the surface of the ovary, leave, in the process of healing, 
corresponding cicatrices. On this account the smoothness of surface is 
soon lost, and it becomes more and more fissured and wrinkled, until, 
towards the end of the childbearing epoch in a woman's life, the ovary 
is so irregular on the surface, as to warrant the comparison which 
Raciborski has instituted between it and the kernel of a peach. After 
this, the organ becomes atrophied, and, like the uterus and other parts, 
is restored, in some measure, to the form which it presented in early 
life. 



V.] MENSTRUATION AND CONCEPTION. 87 



CHAPTEE V. 

MENSTRUATION AND CONCEPTION. 

THE " EUT " OF MAMMALIA: ANALOGY BETWEEN THIS AND MENSTRUATION — THE 
FIRST MENSTRUAL PERIOD: STATISTICS OF DURATION OF A "PERIOD." — QUAN- 
TITY OF THE DISCHARGE — MENSTRUATION A HEMORRHAGE : NON-COAGULA- 
BILITY OF — SOURCE OF THE MENSES : VARIOUS THEORIES REGARDING : IS FROM 
THE MUCOUS MEMBRANE OF THE CAVITY — POUCHET'S THEORY EXAMINED; IS 
THE MUCOUS MEMBRANE SHED? — VIEWS OF KOLLIKER, COSTE, ETC. — DURATION 
OF CHILDBEARING EPOCH — CAUSE OF MENSTRUATION — CONCEPTION — COMPOSI-^ 
TION OF THE SEMEN — SPERMATOZOA AND THEIR DEVELOPMENT — "SPERM- 
CELLS " — THE FUNCTION OF THE GERMINAL VESICLE ; " GERM-CELLS " — HOW 
DOES THE SEMEN REACH THE OVUM ? 

There is, in the animal kingdom generally, a certain periodicity in 
the phenomena which attend the maturation of the Ovum. In the 
Mammalia, there always is a period of excitement, in which the whole 
generative apparatus more or less participates ; succeeded by a period 
of rest, of longer or shorter duration, according to the group or species, 
during which the organs involved are in a state of complete or com- 
parative quiescence. The first marks the period at which the ovum is 
ready for impregnation ; during the latter sexual congress, is, as a rule 
ineffectual. This term of excitement, which is accompanied by general 
and local symptoms to be noticed presently, is called, in mammals 
lower in the scale than man, the rut or oestrus. 

There is not the slightest doubt that, in those animals, the escape of 
the ova from the ovary, and their passage down the Fallopian tube, 
are facts which coincide with the oestrus. The female then manifests 
an instinctive desire for copulation, and is generally said to be at this 
time " in season " or " in heat.' 7 The pudendum is congested and 
swollen, and the glands in this region pour out an abundant secretion, 
which, by its odor, attracts the male. This secretion, unless in those 
animals which come nearest to man in the scale, is very seldom even 
tinged with blood. In some cases, as was demonstrated by Bischoff in 
the case of the roe, the rut occurs only at intervals of a year, about the 
month of August. It is only at this period that the ovaries of the 
female contain ripe ova; and, what is of even higher physiological 
interest, the semen of the male is elaborated then and then only, so 
that impregnation is doubly impossible, save with a view to the birth 
of the young at that time of the year when they may be most easily 
reared. But, in many animals, the maturation and dehiscence of the 
ova occur with much greater frequency, and it is probable that food, 
domestication, and careful tending, may modify the return of those 
periods. 



88 MENSTRUATION AND CONCEPTION. [CHAP. 

In women, during the period of ovulation, there are, as has already 
been shown, certain essential phenomena which are, so far, almost 
identical with what we observe in other mammalia. But there is here 
a special phenomenon superadded, which is in fact the external mani- 
festation of what we know to be taking place internally. This consists 
in a discharge from the uterus of nearly pure blood, which lasts usually 
for several days. It is called the " catamenial " or " menstrual " dis- 
charge, as it occurs very constantly at intervals of a month ; the occur- 
rence being, in its course, usually designated as menstruation. 

A very warm discussion has been maintained for many years as to 
whether the " rut " and " menstruation " are to be held as analogous. 
Up to a certain point, the analogy is admitted by all ; but it must be 
conceded that, between the two, distinctions and even contrasts are 
found, on careful examination, to arise, which seem to challenge the 
truth of the assertion which many have made, that the phenomena are 
•physiologically identical. Without expressing any confident opinion 
as to this quwstio vexata, we may here mention the chief points, in ad- 
dition to the sanguineous discharge, in which they differ. Impregna- 
tion takes place during the excitement of the rut, while as a general 
rule it occurs in women about a week after menstruation, during the 
period of rest. Again, there succeeds to the rut a period of inappe- 
tence, when not only does the female refuse the male, but in some cases 
no semen is, as we have seen, secreted ; in the human species there is, 
strictly speaking, no period of inappetence, not even excepting the 
period of the menstrual discharge, so that at any time impregnation 
may occur. Great as these differences undoubtedly are, and even if we 
admit that they destroy the identity of the acts, they are scarcely suffi- 
cient to warrant us in rejecting the analogy ; for, although the subject 
is still obscure, a more accurate knowledge of the time occupied by the 
descent of the human ovum may show that the above points of con- 
trast are more apparent than real. 

Menstruation is familiarly termed by women the " courses," " monthly 
illness/ 7 or " period." It is not to be looked upon as an isolated act, 
but as one of the important series of phenomena which occur during 
ovulation ; and as such it requires special and careful attention. Its 
first appearance is associated with the other signs of puberty. The 
approach of this is indicated by an alteration in the form of the pelvis, 
and a consequent change in figure and gait ; by the growth of hair on 
the pubes, the rapid development of the mammae, the greater projection 
of the nipple, and the deeper color of the areola. These physical 
modifications are generally associated with very characteristic moral 
changes. A frank romping manner gives place to one more timid and 
gentle, and the loud voice and ringing laughter of childhood is replaced 
by subdued tones and bashful reserve. A Graafian vesicle now for the 
first time comes to maturity, and projects on the surface of the ovary, 
which is embraced by the fimbriae of the Fallopian tube, while the 
whole of the organs, including the uterus, become highly congested. 

According to Boerhaave, the first menstruation is accompanied with 
a certain amount of fever, as the result of the excitement of the genital 
organs. The girl complains of lassitude, hypogastric fulness, lumbar 



V.] STATISTICS OF MENSTRUATION. 89 

and sacral pains, slight itching and tumefaction of the external geni- 
tals, and a painful swelling of the mammae. Not unfrequently, hysteria, 
chorea, and other nervous disorders, manifest themselves, — generally 
in a mild form. After a few days, a mucous discharge, more or less 
abundant, is observed; this becomes tinged with blood, and after a 
time is found to be almost pure blood, to be again replaced by a tinted, 
and finally by a clear discharge, closely resembling that which at first 
showed itself. The previous symptoms disappear with the menses, 
which may have lasted a week ; and she is restored to perfect health, 
but with an indescribable something in manner and appearance which 
marks the transition into womanhood. Such symptoms as are above 
detailed, on the authority of Boerhaave, as accompanying a first men- 
struation, are generally slight in degree, the discharge often appearing 
during sleep, or at any other time, without anything whatever of the 
nature of premonitory symptoms. Very often, for a period or two, 
some of the same symptoms are experienced, at intervals of a month, 
without any flow of blood. These indicate preliminary or abortive 
attempts on the part of nature, — the Graafian vesicles being probably, 
as yet, not perfectly mature ; but there is little reason to doubt, that 
the first maturation of a vesicle is, as a rule, coincident with the first 
menstrual discharge. 

The initiation of this period of a woman's life is believed to be 
hastened by hot climates, by residence in towns, and the habits which 
are there contracted, and by constitutional vigor ; while cold tempera- 
tures, country residence, and a feeble and delicate temperament, retard 
the act. In a certain number of cases, menstruation is postponed to a 
period of life much more advanced than usual. We read, for example, 
of a case in which a woman who had married at twenty-seven, men- 
struated for the first time two months after her eighth labor ; and of 
another who had no discharge until after her second marriage, at the 
age of forty. Numerous cases of premature menstruation are also on 
record, where menstruation has actually appeared during infancy, and 
where the external appearances and sexual desires of maturity have 
been manifested at a very early age. In a case cited by Cams, a child 
menstruated at the age of two years, became pregnant at eight, and 
lived to an advanced age. Such cases are, of course, extremely rare ; 
but of more frequent occurrence are those instances in which women 
become pregnant without ever having menstruated ; while it is by no 
means an uncommon thing for a woman who is nursing, to become 
pregnant again before the menses have returned, such facts indicating, 
as Cazeaux observes, that menstruation plays a secondary part in the 
phenomena of ovulation. 

Putting such exceptional cases aside, as irregular and abnormal, we 
at once recognize the fact, that the time of a first menstruation varies 
greatly, according to climate, constitution, and the kind of life which 
is led. In so far as climate is concerned, the influence exercised by it, 
while quite marked, is by no means so considerable as was once be- 
lieved, and may be represented by a period of three years at the fur- 
thest between the extremes, which we may suppose to exist in the 
Hindoo and the Esquimaux. At one time, ideas were entertained on 



90 



MENSTRUATION AND CONCEPTION. 



[CHAP. 



this subject which more correct observation has shown to be absurd, 
and to no one are we more indebted than to Mr. Roberton, of Man- 
chester, for clearing away the errors which were long promulgated on 
these points. The following table, which shows the period of the first 
menstruation in 8983 cases, is the result of a very careful analysis of 
the most reliable statistics which have been published in Europe on 
this subject. 

Some idea is here given of the variation in the different countries of 
Europe, and shows the very small proportion of cases in which men- 
struation first appears under ten or over twenty-two years. The period, 
as will be observed, varies very considerably, about the age of sixteen 
being the time at which it most frequently shows itself in this country. 
At any age, however, between twelve and twenty, the function may be 
established, without any peculiarity whatever in the attendant symp- 
toms or deterioration of the general health ; but if beyond these limits, 
it may be looked upon as exceptional and irregular, although even 
then, as in the cases alluded to, the health may in no way suffer. 



Age. 


England, j France. 


Germany. 


Norway. 


Russia. 


Total. 


Roberton, Brierre de 
Lee, White- Boismont, 
head, and Raciborski, 
Murphy. Bouchacourt. 


Osiander. 


Faye. 


Lebrun. 


Under 10, 

10 to 13, 

11 " 12, 

12 " 13, 

13 " 14, 

14 " 15, 

15 " 16, 

16 " 17, 

17 " 18, 

18 " 19, 

19 " 20, 

20 " 21, 

21 " 22, 
Over 22, 


14 

64 

103 

278 

595 

1034 

1178 

1307 

714 

531 

213 

104 

18 

17 


16 

41 

138 

209 

258 

355 

411 

349 

287 

190 

102 

66 

31 

23 


3 

8 

21 

32 

24 

11 

18 

10 

8 

1 

1 


4 

4 

13 

14 

20 
13 
13 
6 
8 
3 
o 


1 

15 

27 

35 

13 

6 

2 

1 


30 

105 

241 

494 

865 

1424 

1650 

1727 

1060 

765 

337 

188 

54 

43 


Total, 


6170 2476 


137 


100 


1.00 


8983 



Once established, the menses should return with periodic regularity 
during the whole childbearing epoch. The recurrence of the discharge 
is always attended with local, and generally with constitutional, symp- 
toms. The latter are identical with those which accompany the first 
menstruation, only less in degree, and constitute what has been termed 
the menstrual molimen. The only circumstances which normally arrest 
this function of the uterus are the occurrence of pregnancy and lacta- 
tion, during which the ovarian and uterine functions are generally in 
complete abeyance. If, under other circumstances, it should disap- 
pear during the childbearing epoch, it is regarded as an indication of 
some morbid condition, usually constitutional, and which declares itself 



V.] QUANTITY OF THE DISCHARGE. 91 

as a rule by the presence of other symptoms. It may last from one to 
eight days, eight being, according to Brierre de Boismont, the most 
common, and, strange to say, seven the least so. The following is, ac- 
cording to the same observer, the duration in days arranged in the 
order of frequency in which each day is selected : 

8 : 3 : 4 : 2 : 5 : 1 : 6 : 10 : 7. 1 

The catamenial period and interval together occupy a period of a 
month of four weeks, or twenty-eight days. This is the rhythm of the 
act in such a large proportion of cases, that we may set it down as the 
rule ; but it is a rule to which we find constant exceptions, a few days 
more or less than the limit here mentioned being of constant occurrence, 
much greater irregularities, indeed, being quite compatible with perfect 
health. It is by no means rare to find a woman who menstruates once 
in six weeks or once in a fortnight, without any inconvenience what- 
ever. In all cases, it is the continuance of the flow which mainly de- 
termines the duration of the interval or intermenstrual period. In 
some, and under the influence of morbid conditions, a leucorrhoeal dis- 
charge takes the place of the ordinary menstrual flow ; and, in others, 
the molimen is relieved by a discharge of a hemorrhagic nature from 
some other surface. Both of these conditions, although essentially 
pathological, are, nevertheless, in not a few instances, beneficial in their 
action. 

The amount of the discharge is very variable even in the same 
woman, and very different opinions have been formed as to what is to 
be considered a normal quantity over the whole period. The obvious 
difficulties in the way of such an investigation have hitherto prevented 
anything like a reliable estimate. That of Hippocrates, which we 
have on the authority of Galen, assumes eighteen ounces to be lost at 
each period, but this has not been confirmed, even proximately, by 
any modern observer. Meigs put it down at four to six ounces, Dehaen 
at three to five, and Farre at two to three ; and there can be no doubt 
that these figures give a more accurate idea, and that Farre is probably 
correct when he says " that a discharge, amounting to six or more 
ounces in the aggregate, will generally produce for the time sensible 
effects upon the constitution, such as general pallor, and some feeble- 
ness of the muscular system. " 

In regard to the nature and influence of the menstrual discharge, 
very incorrect and even fabulous opinions were entertained. Pliny 
assures us that the presence of a menstruating woman blights vegeta- 
tion, turns wine sour, and produces a number of other and similar 
effects ; and in some districts, even at the present day, traces of this 
superstition are to be found. The peculiar odor which was described 
by De Graaf, and which has been compared by some French physiol- 
ogists to that of the marigold, is a very usual characteristic of the 
discharge ; but it is scarcely necessary to add that, in the absence of 
any morbid condition, neither this nor any other quality of the dis- 

1 De la Menstruation : par A. Brierre de Boismont. Paris, 1842. 



92 MENSTRUATION AND CONCEPTION. [CHAP. 

charge can produce deleterious results. During the height of the 
period, it is composed, as the researches of Donne, Pouchet, Letheby, 
and others have abundantly proved, almost entirely of pure blood, 
mixed with a certain quantity of mucus. During the periods of in- 
vasion and decline the mucus predominates, the color being in direct 
proportion to the number of blood-corpuscles, which are seen by the 
microscope, mixed with epithelial scales and with mucous corpuscles 
from the cervix. 

There is one striking peculiarity which serves to distinguish this 
from ordinary hemorrhagic discharges — its want of coagulability. This 
was at one time supposed to be of itself sufficient evidence that it was 
not blood, or was blood deprived of its fibrin ; but no doubt now re- 
mains that the arrest of coagulation depends upon the mixture of the 
acid secretion of the vagina with the still fluid blood as it escapes from 
the os, which not only maintains the fibrin in solution, but also renders 
it difficult of chemical detection. When the quantity is excessive, con- 
stituting the affection known as menorrhagia, nothing is more common 
than to find clots discharged, the blood being then so far in excess as 
to neutralize the acid in the vagina. And, besides, it has been proved 
that if the blood be collected as it escapes from the os, and before it 
mixes with the mucus, it is coagulable and alkaline in reaction. These 
facts suffice to prove that the discharge is a hemorrhage. 

Source of the Menstrual Discharge. — There are few subjects in phys- 
iology which have given rise to more discussion than this. Some ob- 
servers have seen blood oozing from the surface of the vaginal mucous 
membrane, while others have traced it to the os and cervix uteri ; and 
on isolated observations such as these, theories on the subject have 
been founded. Admitting the facts upon which these theories have 
an unsubstantial basis, we recognize in them nothing more than ex- 
amples of vicarious menstruation, a term which has been applied to 
those cases in which the menstrual molimen is relieved by a discharge 
through an unwonted channel. That the menstrual discharge has its 
true source in the mucous membrane wdiich lines the cavity of the 
uterus is a fact which admits of no doubt, and has been proved to 
demonstration, by examination of the uteri of women who have died 
during a period ; by accumulation of blood within the cavity in cases 
of atresia of the cervix or of the vagina; and, finally, by the examina- 
tion of cases of chronic inversion of the uterus, which offer peculiar 
facilities for the study of the subject. 

In our view of ovulation, those of the essential phenomena of the 
process which have their seat in the uterus and its lining membrane, 
were left for consideration at this place. In point of fact, we may 
assume that menstruation itself is essentially one of these phenomena, 
which are mutually dependent on each other. Along with the enlarge- 
ment of the ovary and Fallopian tubes already described, a very con- 
siderable enlargement, involving an increase in weight, takes place in 
the uterus. Its vascular apparatus becomes developed and injected 
in an unusual degree. This is especially marked in the case of the 
mucous membrane, on the surface of which, under the epithelium, the 



▼••] 



SOURCE OF THE MENSTRUAL DISCHARGE. 



93 



vascular network already described becomes very distinct where the 
vessels surround the orifices of the utricular glands. The glands them- 
selves are also visibly enlarged, 




Tumefaction of the uterine mucous membrane during 
menstruation. (After Coste.) 



and any difficulty which may 
arise in demonstrating them 
while the uterus is at rest, now 
no longer exists. The mem- 
brane becomes increased in 
thickness, its color is deepened, 
and the temperature of the 
whole womb is raised. The 
result of these changes is that 
the membrane becomes hyper- 
trophied to such an extent that 
it is thrown into convolutions, 
which are soft, pressed together, 
and project into the cavity so as 
to fill it completely, its walls 
being thus no longer smooth 
but wrinkled. (Fig. 47.) M. 
Coste, whose conclusions are 
based upon no inconsiderable 
number of such observations, says that, save as a pathological product, 
no such pseudo-membranous exudation exists, as has been described by 
physiologists of repute. 

A closer examination of the surface shows that, at this period, it is 
dotted over with minute specks, which a low magnifying power proves 
to be small drops of blood occupying the orifices of the utricular glands, 
from which they may be dislodged by gentle compression of the walls. 
This, however, does not determine the ultimate source of the haemor- 
rhagic flow, and it is around this part of the subject that the greatest 
difficulties have arisen. 

That it is not a secretion, in the proper acceptation of the term, as 
was once believed, is a postulate which the analysis of the discharge 
enables us to affirm. We need not therefore address ourselves to the 
refutation of an exploded theory. The view entertained by Coste, is 
that it is a transudation through the walls of capillary vessels, chiefly 
venous, or in other words (if we do not misunderstand him) that a con- 
siderable haemorrhage takes place in this manner, without any breach 
whatever in the walls even of the smallest vessels, a conclusion which 
all physiological analogy forbids us to accept. That there may be 
permanent vascular orifices through which the blood escapes during the 
menstrual period is an idea which has found favor in the eyes of some 
eminent physiologists, among others Dr. Far re. Nor is this so fanciful 
a view as one might be disposed at first to consider it. If there are 
permanent orifices, it may indeed be asked, why is there not continuous 
haemorrhage? And in reply, it may be assumed, hypothetically of 
course, that these orifices are, during the intermenstrual period, closed 
by the contractility of the tissues which surround them ; but that the 
increased vascularity, tumefaction, and relaxation of all these parts, 



94 MENSTRUATION AND DISCHARGE. [CHAP. 

which coincide so constantly with the other phenomena of ovulation, 
admit of a welling forth of pure blood through apertures which now, 
under the special circumstances, become patent, and which, the apogee 
of the period having passed, forthwith commence to close, to open 
afresh on the approach of the next menstruation. 

The theory, however, which perhaps of all others has attracted in 
recent times the greatest amount of attention, is that which is associated 
chiefly with the name of M. Pouchet, and to this theory some of the 
ablest of our English writers have given their adhesion. Pouchet — if 
we mistake not — supposed that the whole, or at least the greater part 
of the mucous membrane (not the epithelium merely) is shed at each 
catamenial period ; and that its separation from the subjacent tissues 
involves the rupture of vessels, whence the menstrual flow. This, 
however, would involve a very different appearance of the internal 
surface of the uterus, from that which has been above described as 
occurring at this time, and which we believe to be substantially correct. 
A separation of a membrane so thick and so important Avould, in fact, 
be capable of obvious anatomical demonstration ; and if it could be so 
demonstrated, we would at once have, in the trunks of the vessels which 
must of necessity be ruptured, the source, clear and unequivocal, which 
we are endeavoring to trace. The separation of the mucous membrane 
of the uterus, under the name of decidua, which occurs in women at the 
moment of delivery ; and the occasional occurrence of what is known 
as membranous dysmenorrhea, when, in certain morbid conditions, 
the whole membrane is actually exfoliated, and shed either piecemeal 
or entire, are facts which have seemed to M. Pouchet sufficient to 
establish an analogy, on which, mainly, his theory is based. The 
mucous membrane, he says, is deciduous not merely at the termination 
of pregnancy, or as a consequence of an exceptional morbid action, but 
at each menstrual period. No such separation takes place in the lower 
animals, and in this distinction we find revealed at once the source of 
the menstrual discharge, and the reason why, in the human species, 
haemorrhage is superadded to the ordinary phenomena of " rut." In- 
genious as this theory may be, and interesting as the facts undoubtedly 
are which its promoter has brought to bear upon it, it is one, we think, 
which requires closer investigation. 

If M. Pouchet could show us the exfoliated membrane, and the raw, 
bleeding surface which its removal necessarily involves, as he might 
do in membranous dysmenorrhea, or in women who have died shortly 
after delivery, his theory would be established, and the question for- 
ever set at rest. But in this he has scarcely succeeded. Opportuni- 
ties of examining the bodies of women who die during a menstrual 
period are, no doubt, rare ; but, a sufficient number of such examina- 
tions have been made by Coste, and, more recently, by Kundrat and 
Engelman, to show what is the usual condition of the parts. In a 
certain number of cases, no doubt, something approaching to complete 
exfoliation does occur, but even Pouchet himself is forced to admit that 
these cases are exceptional. His ultimate conclusion seems to be that 
the membrane desquamates, not during menstruation, but in the inter- 
val. This, however, abandons all the advantage which he gained from 



V.] CAUSE OF MENSTRUATION. 95 

the analogy which he so ingeniously established. For there can be no 
comparison between a desquamation occurring when the functional 
activity of the womb is in abeyance, and one which is uniformly asso- 
ciated with its highest functions ; although an analogy might fairly 
enough have been traced between the birth of the decidua, in the final 
act of parturition, and the shedding of the same membrane in connec- 
tion with a process which is held to be, up to a certain point, prepara- 
tory to the reception and development of the ovum. 

The separation of the membrane from the subjacent structures would 
certainly, if occurring during menstruation, account satisfactorily for 
the discharge; but, even if it were established that an intermenstrual 
exfoliation did occur, this would, in no sense whatever, account for the 
periodical phenomena of menstruation. Dr. Tyler Smith states, that, 
having had several opportunities of examining the uteri of women who 
had died during menstruation, he found that the appearances presented 
were similar to those which are observed after abortion. "In each of 
those cases," he says, " I found the mucous membrane of the body of 
the uterus either in a state of dissolution, or entirely wanting." In 
one case — of which he gives a drawing in his "Manual" — he found 
that " in the cervical canal the mucous membrane was perfect, but at 
the os uteri internum it ceased as abruptly as though it had been dis- 
sected away with a knife above this point. Blood was oozing at 
numerous points, from broken vessels in the submucous tissue." In a 
microscopic examination of this case, in which he was assisted by Dr. 
Handfield Jones, no traces of the epithelium or utricular glands could 
be found. Now, if Dr. Tyler Smith founds his belief in the exfoliation 
theory, on such cases as this, he goes much further than Pouchet him- 
self, in attempting to prove, w r hat that physiologist does not, that the 
separation of the membrane occurs during menstruation. Speaking 
with that respect for his views to which such an eminent observer is 
entitled, we are inclined to assume that Dr. Tyler Smith w r as mistaken, 
and that the case was either a very exceptional one, or that he mistook 
shedding of the epithelium for separation of the entire membrane. 

We believe that, in all probability, the views of Kolliker, which 
have been recently, in some degree, confirmed by Robin, point to a 
more correct conclusion than any of the theories above stated. These 
distinguished histologists believe, with Coste, that the mucous mem- 
brane becomes thickened during menstruation. They hold, however, 
that the blood escapes from ruptured superficial capillaries, the epithe- 
lium covering the mucous membrane of the body being, in great part, 
thrown off. The interesting observations of Robin, as to the structure 
of the utricular glands, make it more than likely that -a considerable 
portion of the discharge comes from these ; but that it comes from the 
surface of the membrane as well, and probably, to a trifling extent, 
from that of the Fallopian tubes, we may consider as certain. There 
can be little doubt, however, that a certain change does take place in 
the epithelium during menstruation. Independent observers have 
shown, for example, that, as during pregnancy, so also at this time, 
the epithelium is deprived of its vibratile cilia. Farre has occasionally 
observed, in an injected uterus, that the capillary vessels, which form 



96 MENSTRUATION AND CONCEPTION. [CHAP. 

so fine a network upon its inner surface, are " denuded, and hanging 
forth in detached loops." Such observations, taken along with the 
fact that epithelial cells, and a certain amount of debris, are found 
mingled with the catamenial discharge, suffice, we think, to prove that, 
during menstruation, the flow of blood is from the mucous membrane 
of the cavity, and that certain changes in, and probable loss of the 
epithelium, are associated with the flow. 

The view above expressed has received recent confirmation from the 
interesting observations of Kundrat, above referred to. As the result 
of microscopic researches in the case of women who were either men- 
struating or pregnant at the time of their death, he concludes that a few 
days before the menstrual flow is established, a proliferation of the 
cells of the interglandular tissue takes place, by which that portion of 
the mucous membrane which lies nearest the cavity becomes infiltrated 
with newly formed round cells. When the capillary vessels rupture, 
these cells have already passed through a stage of cloudy swelling and 
fatty degeneration, and it is this superficial portion of the mucous mem- 
brane which is thrown off during the continuance of the discharge, and 
for some days after its cessation. To this extent, then, we hold it to 
be established that the mucous membrane of the uterus is shed at each 
menstrual period ; and that Pouchet's theory, as corrected by more 
modern research, is not so wide of the truth as it at first appears. 

The menstrual, or childbearing epoch of a woman's life ranges on 
an average from twenty-five to thirty years, ceasing most frequently 
between the ages of forty-five and fifty. So long as the woman enjoys 
perfect health, the appearance of the discharge should be at regular in- 
tervals, of which the normal duration is twenty-eight days. Some 
women, however, as is well known, menstruate every three or every 
six weeks, and we are only justified, practically, in looking upon such 
cases as abnormal, when the general symptoms are such as to call for 
interference. Irregularities occur, too, as we have already seen, fre- 
quently enough during the first months of menstruation; and we find 
also that, as the catamenial climacteric or change of life approaches, the 
cessation of the menstrual function does not occur abruptly, but after 
marked premonitory symptoms. At this period of her life, a woman 
becomes subject to many hysterical and other minor ailments, from 
which she may previously have enjoyed an entire immunity. A period 
may, possibly for the first time, pass without discharge. On the next 
occasion, an increased quantity seems as it were to compensate for the 
omission which nature had made. Intervals of longer duration may 
now succeed, intervals which bear no relation to former menstrual 
epochs, until after a certain number of fitful and capricious efforts on 
the part of the uterus to relieve itself as before, the catamenia finally 
cease ; the uterus becomes less in size, and the ovaries shrink so rapidly, 
that they become wrinkled on their external surface, so as to resemble, 
as Raciborski says, the kernel of a peach. The only normal exceptions 
to regular menstruation are pregnancy and lactation ; but even these 
are by no means regular in their occurrence, as we occasionally meet 
with cases where women continue to have their periods for some time 
after conception, and frequently with others where, during lactation, 



V.] THE SEMINAL FLUID. 97 

menstruation goes on with perfect regularity. Any menstrual irregu- 
larity, however, occurring during the period of a woman's life which 
we are here considering, and independent of pregnancy, is to be looked 
upon as an abnormal state, which calls for treatment with a view to 
the maintenance of her health. These, and other menstrual disorders, 
constitute a class of diseases to the treatment of which the physician 
has constantly to address himself. 

The cause of menstruation is a question which has given rise to a 
great deal of useless discussion, and to not a few baseless theories. 
Without broadly asserting that the two phenomena stand to each other 
in the relation of cause and effect, we are, in the present state of our 
knowledge, entitled to assume that the periodical discharge depends 
upon corresponding changes in the ovary, associated with the matura- 
tion of a Graafian vesicle. This is proved by the examination of the 
ovaries of women w T ho have died during menstruation, when the ap- 
pearances already described are generally to be found; by the almost 
invariable cessation of menstruation when the ovaries have been re- 
moved; 1 and by the facts which a careful examination of the phenomena 
of the "rut" of the lower animals discloses. Why the act should 
recur at periods so regular and constant, is a question which we need 
scarcely attempt to answer. That, in one animal, a single Graafian 
vesicle should come to maturity each month, in another, a cluster ripen 
simultaneously, and, in a third, that evolution should occur at intervals 
of a year, are facts which display a marvellous accordance with the pur- 
poses of nature in regard to the propagation of species, but they are 
facts, too, the ultimate cause of which will continue to baffle the specu- 
lation of the astutest intellects. 

Conception, Fecundation, and Impregnation, are terms all of which 
imply fruitful contact of the male and female elements, so that a new 
organism comes into existence. The fecundating principle which is 
contributed by the male is secreted by the testes at the age of puberty, 
and is known as the semen or seminal fluid. At the time of sexual 
contact, the excitement of the erectile tissue is such, that, acting through 
the medium of a ganglionic centre, which is supposed to be situated in 
the lower portion of the spinal cord, it culminates in an orgasm, during 
which certain muscular fibres are called into a reflex and convulsive 
action. The semen is thus ejaculated with considerable force by the 
fibres of the vasa deferentia, and by the special muscles which sur- 
round the vesicula? seminales and the prostate gland, its regurgitation 
towards the bladder being prevented, according to Kobelt, by the 
tumefaction of the verumontanum which occurs during the period of 
erection. It is thus thrown for the most part into the upper part of 
the vagina, and over the os and vaginal portion of the cervix; but it is 
well known to medical jurists that this, although highly favorable to 
impregnation, is not essential. On the contrary, there are perhaps few 

1 Percival Pott's well-known and often-quoted case, corroborated by similar ob- 
servations by Cazeaux, Oldham, and others, was long held as conclusive evidence 
that menstruation in the absence of the ovaries was impossible. A sufficient num- 
ber of cases have, however, been reported on good authority to show that, excep- 
tionally, periodic sanguineous discharges may go on in the absence of the ovaries. 

7 



98 MENSTRUATION AND CONCEPTION. [CHAP. 

physicians of experience who have not met with cases where women, 
believing themselves safe, have permitted a certain amount of sexual 
contact without penetration, and have thus become pregnant. All, in 
fact, that seems to be essential is contact of the seminal fluid with the 
pudendum, which is further proved by observations of pregnancy coin- 
cident with perfect hymen. 

The semen is a thick, glutinous, whitish fluid, albuminous, heavier 
than water, and emitting a peculiar odor. If subjected to exami- 
nation by a considerable magnifying power, it is found to consist of a 
number of little oval, flattened bodies, which in man are not more than 
%-qqq of an inch in width, furnished with long filiform tails, which 
taper gradually to the finest point. A lashing undulating motion is 
imparted to these bodies, for a certain time after death or ejaculation, 
varying according to circumstances from several hours to several days. 
This brisk and constant movement, which has led Kolliker to compare 
them to ciliated cells, gave rise to the erroneous opinion that they were 

animalcules, hence the name which 
they still retain, Spermatozoa. Besides 
these bodies, there are observed cer- 
tain minute round and granular masses, 
varying in number, but always fewer 
in ripe semen than the Spermatozoa 
themselves. These are what were 
originally termed by Wagner, " semi- 
nal granules," but which have been 
shown by his subsequent researches, 
and by those of Kolliker, Leuckart, 

Spermatozoa and vesicles of evolution. etc., to be Cells within which the Sper- 

matozoa are developed, and are now 
termed vesicles of evolution. These again are generally found to be 
inclosed in groups of from three to seven within parent cells (Fig. 48, 
b b), but each vesicle of evolution is destined for the development of a 
single spermatozoon, as is shown in a mature specimen at c. The indi- 
vidual spermatozoa escape thereafter by rupture of the containing vesi- 
cle, and may now (a) exhibit their characteristic movements. Some- 
times, rupture of the vesicles of evolution takes place without absorption 
of the parent cell, when the appearance produced is that shown at d, 
where a bundle of spermatozoa is seen, their number corresponding to 
that of the original vesicles. It is only, it may be observed, by careful 
examination of the semen in the testes, epididymis, and other portions 
of the tract, that these several stages may be traced. These elements 
of the semen are found to float in a limited quantity of clear perfectly 
homogeneous liquid. Direct experiment on the ova of the Amphibia 
has proved that it is in the spermatic particles and not in this fluid 
that the fecundating principle resides. If the spermatozoa are absent, 
therefore, as in debility, disease, or old age, impregnation is impossible, 
and it is their absence in the semen of hybrids that renders these ani- 
mals sterile. 

The Ovum at the stage at which we left it, was escaping, or about 




V.] CONTACT OF OVUM WITH SPERMATOZOA. 99 

to escape, from a ripe Graafian follicle. It is then composed of the 
following parts (see Fig. 39, p. 79): 

a. Of a thick transparent membrane, which completely surrounds it, 
and exhibits no trace of vascularity — the zona pel lucida of Baer, or 
vitelline membrane of Coste : 

b. Of a granular yolk contained in this vesicle : 

c. Of the germinal vesicle of Purkinje : 

d. Of the germinal spot of Wagner. 

The Germinal Vesicle, as the period of dehiscence approaches, moves, 
as we have seen, towards the periphery of the yolk, both it, and the 
germinal spot within it, being so placed, as to be as near as possible to 
the point where rupture is about to occur, as if to seek the fertilizing 
influence of the male. Since Bischoff actually demonstrated the pres- 
ence of spermatozoa on the ovaries of bitches and rabbits, in whom 
congress had been permitted at the proper period, few physiologists 
question the possibility of impregnation occurring while the ovum is 
yet in the ovary ; and indeed, if true ovarian pregnancy is possible, 
— which some doubt, — it is only in this way that impregnation can, in 
these cases occur. It has been generally assumed, however, that a 
rupture of the walls of the Graafian vesicle could alone permit of such 
impregnation ; but if we may so far judge from analogy, what has 
recently been divulged in reference to the penetration of the walls of 
bloodvessels by the white corpuscles of the blood, and their consequent 
transformation into pus-cells, we may at least admit the possibility that 
particles endowed with such mobility may penetrate the attenuated 
walls of a Graafian vesicle, even before rupture. 

The germinal vesicle has been designated by some physiologists the 
germ-cell, and the vesicle which contains the spermatozoon the sperm- 
cell, it being assumed that the fertilizing product of the latter made its 
way through the walls of the ovum, and intermingled with the con- 
tents of the former. In the osseous fishes, and in some animals lower 
in the scale, it has been shown that a minute opening (micropyle) exists 
in the zona pellucida, which has been supposed by Dr. Allen Thomson 
to facilitate the fecundation of ova possessed of very thick external 
coverings. No reason other than this exists for the belief, which some 
have entertained, that a similar aperture in the Mammalia facilitates 
the introduction of the spermatozoa. There are many reasons for be- 
lieving frhat the germinal vesicle, or germ-cell, plays an important part 
in conception, but what precise share it takes in the process is hitherto 
undetermined. 

The cessation of the characteristic movements of the spermatozoa 
marks the termination of the period during which their fertilizing in- 
fluence may be exercised. The duration of the period will, therefore, 
obviously depend upon the circumstances under which the semen is 
placed. Its admixture, at the time of ejaculation, with the prostatic 
fluid and the secretion of Cowper's glands, and, subsequently, with the 
vaginal and uterine secretions, are obviously circumstances which tend 
to preserve the spermatozoa, by furnishing a medium in which they 
may freely float : an absence of these conditions would necessarily cur- 
tail their vitality. Although we may assume it as possible that im- 



100 MENSTRUATION AND CONCEPTION. [CHAP. 

pregnation may occur in'the ovary, it by no means follows that it can 
occur nowhere else. But it is certain that the contact between the 
male and female elements must almost always take place, if not in the 
ovary, at some point between it and the upper third of the uterine 
cavity. Bischoff affirms that, by the time the ovum reaches the lower 
end of the Fallopian tube, its capacity for impregnation is lost, and 
experiments which have been made, by tying the Fallopian tubes in 
the lower animals before copulation, so far corroborate this view, which 
is now generally entertained. There can at least be little doubt that 
in the great majority of cases among Mammalia, and most probably in 
the human subject, it is in the upper half, or third, of the Fallopian 
tube that the meeting of the ovum with the semen takes place. 

How, then, do the spermatozoa reach the ovum? It cannot for a 
moment be doubted that the spermatozoa must make their way upwards, 
in Man, as in the lower animals, from the vagina, to that point where 
they meet the ovum. 1 There are various possible agencies by means 
of which this movement may be effected : 1st. By the action of the 
spermatozoa themselves, which may undoubtedly determine a motion, 
although it is difficult to conceive why such motion should be in a 
definite direction. It is highly improbable, therefore, that this is the 
sole motive. 2d. By the action of the vibratile cilia. This will 
account, no doubt, for the movement from the middle of the cervix 
upwards ; but in cases where impregnation has resulted from contact 
without penetration, the absence of cilia between the vulva and the 
cervix must leave the movement along this part of the tract to the 
operation of some other agency. 3d. Muscular peristaltic contractions 
may also act by propelling the semen in a definite direction. There 
are various parts of the course which the semen must traverse to which 
one or other of these forces may be more applicable, but it is more than 
likely that muscular peristaltic action is the chief moving power. 

The absence of the vibratile cilia during a menstrual period may 
raise a difficulty as to the acceptance of one of the above theories, most 
likely to suggest itself to those who entertain the strongest views as to 
the identity of the rut and menstruation. But, in regard to this it 
must be observed, that the period at which impregnation is most likely 
to occur is some days after, or shortly before, menstruation ; in the one 
case, the changes in the epithelium of the uterine mucous membrane 
not having yet commenced, and, in the other, a sufficient period having 
elapsed to admit of its reparation. Another channel through which, 
in exceptional cases, the spermatozoa may work their way up, is one 
which, on the authority of Mauriceau, De Graaf, and Baudelocque, 
Cazeaux assumes to result from a bifurcation of the Fallopian tube 
near its uterine extremity, the new canal passing through the uterine 
walls, and opening near the internal os. As modern anatomists make 
no mention of such a canal, we may assume its existence to be doubtful ; 
and even if we admit it, its only physiological importance would be 
the possibility of the arrest of the ovum there, and the formation of 

1 Some speak of the "ovum" only after impregnation, and term it "ovule" 
prior to this. 



VI.] DEVELOPMENT OF THE OVUM. 101 

what has been called by the older writers " Graviditas in substantia 
uteri. " 

A sketch of the development of the ovum, from the period of im- 
pregnation onwards, will be reserved for the following chapter. 



CHAPTEE VI. 

DEVELOPMENT OF THE OVUM. 

formation of the embryo-cell — cleavage of the yolk — development of 
the blastodermic vesicle — " serous " and "mucous" layers — the 
area germinativa and primitive trace — formation of the embryo ; 
of the umbilical vesicle and omphalo-mesenteric vessels ; of the 
amnion; of the allantois and umbilical vessels; of the chorion — 
the liquor amnii — the vitriform body — the decidua ; what is it? 
dec1dua vera ; reflexa ; serotina — early connection of ovum with 
decidua — the umbilical cord : vessels ; gelatin of wharton, etc. — 
knots on cord — the placenta — in birds: in non-placental mammals : 
in ruminants: in man: maternal and fcetal surfaces of: maternal 
circulation in: curling arteries: sinuses: veins — fcetal portion: 
arteries : tufts or villi : veins — functions of the placenta — struc- 
ture of villi. 

The development of the ovum in the Mammalia, and especially in 
Man, is, as regards its earlier stages, a subject still involved in no 
little obscurity. The important results which have sprung from the 
studies in comparative physiology, associated with the names of V. 
Baer, Rathke, Bischoff, Remak, Kolliker, and many others of scarce 
inferior merit, enable us, with a certain amount of confidence, to fill up 
gaps in an account of human development, which the very rare oppor- 
tunities afforded of examining human ova would probably never have 
revealed, but which the application of strict analogical reasoning enables 
us to supply. On these principles, the following sketch is based. No 
attempt will, however, be made to follow the development of individual 
organs ; but merely to indicate, in what appears to the writer to be the 
simplest possible manner, the mode in which the envelopes of the 
embryo are evolved, and the provision which, in successive stages of 
growth, is made for its nutrition. 

The disappearance of the germinal vesicle is one of the earliest 
changes which has been observed. This is not necessarily associated 
with impregnation, but is rather a sign of the complete maturation of 
the ovum. Modern physiologists indeed appear to believe that, as a 
rule, it has nearly, if not entirely, disappeared at the time of the rup- 
ture of the Graafian vesicle. The formation, however, in its place, of 
the new embryo-cell, which, having been demonstrated in many animals, 



102 



DEVELOPMENT OF THE OVUM, 



[CHAP. 



is assumed to take place also in the human species, and the changes 
which immediately occur in the yolk, are undoubted results of the 
fecundating process, and of the penetration of the walls of the ovum 
by the spermatozoa. In the outer half of the Fallopian tube, the ovum 
is believed to have already undergone some of these changes. There 
can be little doubt, at least, that, even thus early, the germinal vesicle 
and its spot can no longer be distinguished, and the external surface of 
the ovum is still covered with some of the granulations in which, within 
the Graafian vesicle, it was imbedded. The yolk becomes more com- 
pact, and, as it were, condensed. In the inner half of the tube, the 
granulations have disappeared, and their place is occupied, on the ex- 
ternal surface of the ovum, by a thin albuminous layer, which is anal- 
ogous to the white of the egg in birds. This albuminous layer, like 
the subjacent zona pellucida, becomes, in the first instance, thicker, and 
there now commences that most remarkable series of changes prepara- 
tory to the formation of the embryo, known as the segmentation, or 
cleavage of the yolk. 

The first step in this process consists, as is shown in Fig. 49, of the 
fission of the mass of the yolk into two equal portions, by a deep 



Fig. 49. 



Fig. 50. 



Fig. 51. 




Successive stages of the cleavage of the yolk. 

furrow on either side, which ultimately, by uniting in the centre, com- 
pletes the division. These again, by a repetition of the process, become 
subdivided, so that four spheres are now observed to occupy the cavity 
of the zona pellucida. Each of these divisions of the yolk proceeds, 
pari passu, with a corresponding duplication of the " embryo cell," 
already referred to. After precisely the same fashion, the spherules 
become still further subdivided into 8, 16, 32, 64, and so on, until, on 
the arrival of the ovum at the uterine extremity of the Fallopian tube, 
the yolk presents the appearance shown in Fig. 51, which has been 
well compared to a mulberry. It is from this germ-mass that the whole 
organization of the embryo is gradually evolved. In Mammalia, the 
process of segmentation affects the whole mass of the yolk, which is 
protoplasmic. But there are great differences in this respect in other 
animals. In Birds and Reptiles, the cicatncula, or white spot, lying 
on the side of the yolk which floats uppermost, alone undergoes this 
process. A distinction is, therefore, to be made between the ova of 
these animals in which the yolk is entirely segmented, and is therefore 
germinal, and those in which a part only is directly germinal and 
another is nutritive. 

Having arrived in the uterine cavity, the ovum, on examination, 



VI.] 



THE BLASTODERMIC VESICLE. 



103 



Fig. 52. 



^^. 



appears as if the whole of the granular germ-mass had been absorbed. 
And to some extent, no doubt, a process of solution or absorption has 
taken place, the centre of the cavity being again occupied by a fluid 
which is limpid and transparent. A more careful examination shows, 
however, that a large proportion of the granules become condensed 
towards the inner surface of the zona pellucida, assuming the form of 
true cells, of a hexagonal or pentagonal appearance from the pressure 
which they exercise upon each other. While these changes are going 
on, a rotatory movement of the yolk takes place, during which, possibly 
by centrifugal attraction, the cells retreat from the centre towards the 
circumference, and ultimately form a new membrane. This spheroidal 
vesicle within the zona pellucida, 
is the structure out of which, step 
by step, the entire embryonic struc- 
tures are evolved. It is the blasto- 
dermic vesicle of Bischoff and Coste. 

From the shape of the cells of 
which it is originally composed, the 
ovum now presents the appearance 
shown in Fig. 52, which indicates 
also a considerable increase in size, 
owing to the rapid augmentation of 
its fluid contents by absorption from 
the uterus, and the simultaneous de- 
velopment of the blastodermic vesi- 
cle, which now exhibits great and 
independent vital energy. At one 
point of its surface, a certain num- 
ber of the original segmentary masses and cells form, by their aggre- 
gation, the appearance which is represented in the same figure. This, 
which is at first round, and subsequently becomes oval, is recognized 
by its whitish opaque appearance. It is called the area germinativa, 
and constantly increases in size by the development of fresh cells, and 
by and by splits into two layers, a division which rapidly extends 
throughout the whole blastodermic vesicle. The external of these two 
layers was originally called the " serous," the internal the "mucous" 
layer. As our object is to enter upon this subject only in so far as is 
essential to a knowledge of the points in development which are of 
special obstetric interest, we shall here refer to these two layers only. 
There is another layer, however, intermediate between the two, which 
further subdivides as evolution advances, a knowledge of which is 
essential to a thorough description of the various organs. This was 
first called the "vascular" layer, but there are many points in reference 
to it which are still under consideration, and in a measure involved in 
obscurity. This seems to be an additional reason why, even at the 
risk of a charge of inaccuracy here and there, we should not enter upon 
the difficult subject of the intermediate layer. 

The area germinativa, at first homogeneous in appearance, soon 
shows in its centre a clear space, called the area pellucida, bounded by 
a denser layer of cells, which are manifestly more opaque. The first 




External surface of the ovum, showing the area 
germinativa. 



c 




104 DEVELOPMENT OF THE OVUM. [CHAP. 

appearance of definite embryonic structure is a shallow groove lying 
lengthwise in the area pellucida. This is the primitive trace, the earliest 

indication of the cerebro- 
spinal canal. If viewed in 
section, this groove (Fig. 
53 a) is seen to lie between 
two lateral eminences called 
the lamince dorsales (c c), 

Diagram showing the earliest format^ of the embryo. which We here demonstrate, 

as it illustrates a law in de- 
velopment, of which, in the evolution of special organs, we find many 
illustrations. This diagram, after Remak, is the only one in the series 
in which the middle layer is indicated, showing at o the first trace of 
the vertebral column, and at p p the subdivision of this layer, indicat- 
ing the origin of the pleuro-peritoneal cavity. The lowest in the figure 
is the mucous layer. In the development of the tube of which the 
groove is the trace, the lamina? dorsales rise, and, folding together, meet 
in the middle line, and there unite. Consequently the cutaneous or 
corneal layer (Hornblatt of Kolliker) secretes from a portion of its sur- 
face elements which, within the tube, ultimately become the cerebro- 
spinal nervous centre. Among other instances of this method of de- 
velopment by involution, the formation of the lens and vitreous body, 
in the construction of the eye, is a striking example, both the cuticle 
and these structures being originally portions of the same external or 
corneal surface. 

The albuminous layer having now disappeared, and the zona pellncida 
having in great part lost its thickness, the formation of the embryo be- 
comes more distinctly manifested by a rolling or folding inwards both 
of the sides and of the extremities of the area germinativa. At this 
stage, the embryo has the appearance of a curved gutter, with a larger 
(cephalic) and a smaller (caudal) extremity. A glance at the diagram 
(Fig. 54) will show that its external or epidermic surface is continuous 
with the external or serous layer (s) of the blastodermic vesicle. About 
this period, the blastodermic vesicle becomes divided into two parts, as 
is indicated by the horizontal dotted line in this and the following 
diagram, the lower portion being embryonic, and the large cavity above 
forming the umbilical vesicle (u). The embryonic portion constantly 
increases, while the umbilical vesicle progressively diminishes, as if the 
development of the former took place at the expense of the latter: this 
is made clear in the series of diagrams. The two small projections (a a) 
show the earliest stage of the formation, by a process of involution, of 
the amnion, an important structure, the further development of which 
will be traced presently. The blastodermic vesicle, then, is surrounded 
by the zona pellucida z. It is itself composed of two layers, the ex- 
ternal or serous (s), which is continuous with the external surface of 
the embryo, and from which the amnion is developed ; and the internal 
or mucous (m), which subsequently subdivides as we have seen. If we 
look, however, at the mucous layer, in its original and simplest form, 
we may assume that the umbilical vesicle and the intestinal surface of 



VI.] 



THE AMNION AND CHORION. 



105 



the embryo are identical and continuous, both being derived from the 
same layer. 

In Fig. 55, the same parts are shown in a more advanced stage of 
development. The embryonic portion of the blastodermic vesicle is 
more defined, and of larger size, and the umbilical vesicle is diminished 
in a corresponding degree, while the communication between the two 



Fig. 54. 



Fig. 55. 





Diagram showing early stage of 
development. 



Further development of the ovum. 



is rendered more distinct. The first indications are now shown on the 
latter of a vascular system. This is the omphalo-mesenteric system, or 
circulation of the yolk, from which is formed ultimately the portal 
circulation of the foetus. The umbilical vessels spring, as we shall 
see, from another source. The amnionic folds (a a) are now seen to 
project more over the embryo. 

The next step in the process of development is shown in Fig. 56, in 
which the whole ovum shows an increase in size. The amnionic folds 
project so far that they are nearly in contact, the embryo being thus 
inclosed in a sac, which has as yet an opening at a a. About this 
period, a very important structure, the allantois, makes its first ap- 
pearance under the form of a small pear-shaped vesicle (p), which 
springs from the mucous layer, near the caudal extremity of the 
embryo. This little organ has, as we shall find, a most important 
part to play in providing an apparatus, and channel of communication, 
whereby the circulation and respiration of the foetus may be efficiently 
maintained. This vesicle, in Birds, reaches a very considerable size, so 
much so as completely to surround the yolk sac, so that, through the 
shell and its membrane, it comes into actual relation with the external 
air. In those mammals, in whom the placenta (an organ to be here- 
after described) surrounds the ovum, the allantois has in like manner 
a considerable development; but, in the human race, where its function, 
though not less important, may be said to be comparatively of a tem- 
porary nature, it never reaches any considerable size. It is originally 
hollow, and is the receptacle for the secretion of the Wolffian bodies, 
and subsequently for that of the true kidneys when formed. It is not, 
however, correct to suppose that it gives origin to the urinary bladder, 
but its pedicle, the urachus, forms the suspensory ligament of the 
bladder, and may be traced in adult life. At a very early period of 



106 



DEVELOPMENT OF THE OVUM. 



[CHAP. 



its formation, vessels make their appearance upon it, and shortly after 
this (probably in a few days) it becomes elongated and, as it were, 'pro- 
jects these vessels, which are the umbilical arteries and veins, towards 
the surface of the ovum, with which it comes into contact at that part 
where the placenta is about to form. It is not, indeed, until this has 
taken place that the outer of the two foetal envelopes may probably be 
said to be completed. 

The foetal covering here alluded to is the chorion, which may thus be 
considered as composed of the external or serous layer, with the remains 
— should these still exist — of the zona pellucida on its external, and 
some portions of the allantois on its internal surface. The Chorion 
thus constituted, becomes abundantly supplied with vessels from the 
allantois, which soon pervade it in its whole extent, as is shown in the 
accompanying diagram (Fig. 57). Prior to this, small projections have 



Fig. 57. 



Fig 56 




Development in a more advanced 
stage. 



Completion of the amnion, and formation of the 
umbilical cord. 



appeared on the external surface of the chorion, which are the rudi- 
ments of the long shaggy villi with which the ovum is seen to be covered 
in abortions occurring in the early weeks of pregnancy. The allantois 
having now fulfilled its function, dwindles to a mere cord, within 
which a minute vesicle may be detected by careful examination, as 
representing the original cavity. It is probable that the allantois 
forms about the tenth clay after impregnation, and runs its course in a 
few days more ; so that it is not to be wondered at, that some physiol- 
ogists have doubted its existence in the human race, seeing that its 
limits have not been clearly demonstrated. Analogy, however, enables 
us confidently to assume that, without it, there could be no vascularity 
of the chorion, a condition which would involve a speedy arrest of 
development. At first, it carries two arteries and two veins ; but the 
vein of the right side becomes obliterated about the fifth or sixth week, 
so that there are found from this period till the time of birth, two 
umbilical arteries and one umbilical vein. 



VI.] THE AMNION AND CHORION. 107 

After the formation of the allantois, the umbilical vesicle rapidly 
shrinks, and is often seen, in abortions at the sixth week, under the 
form of a vesicle no larger than a pea, connected with the small intes- 
tines of the embryo by means of a long and narrow 7 pedicle ; and its 
flattened yellowish vestige may with care be detected much later, lying 
not far from the place of implantation of the umbilical cord into the 
placenta, between the chorion and amnion. (See Fig. 71.) The om- 
phalo-mesenteric vessels atrophy, along with the organ to which they 
belong; and the communication which existed between the vesicle and 
the alimentary canal, becomes more and more curtailed, and ultimately 
obliterated. There can be no doubt, however, that in the earliest stages 
of the development of the ovum, and up to the period of the formation 
of the allantois, the embryo derives its chief nourishment from the 
whitish-yellow fluid, which is contained in the umbilical vesicle, and 
which has been found to contain numerous fatty cells and globules. 
But, with the formation of the allantois and the vascularity of the 
chorion, the necessity for nutrition from this source ceases, and the 
umbilical vesicle, which at one time formed the greater part of the 
bulk of the ovum, now withers, and ultimately disappears. 

At the same time that this dwindling of the umbilical vesicle takes 
place, the development of the amnion goes on with considerable rapidity. 
In Fig. 57 the completed process of involution, which results in the 
formation of the cavity of the amnion, is shown, as are the earlier stages 
in the preceding diagrams. The amnion thus forms a close cavity or sac, 
which consists of two layers, and is contractile; and in which, hence- 
forth, the foetus floats freely, protected by the fluid which it contains, 
from shock and external influences. By the absorption of the original 
amnionic folds, at the point where they come into contact (see the dot- 
ted line below a), the amnion becomes completely detached from that 
portion of the serous layer of the blastodermic vesicle, which we have 
shown to enter into the formation of the chorion. The amnion thus 
forms a sheath for the umbilical cord, and from the margins of the 
ventral aperture or umbilicus, is continuous, as it has been from the 
first, with the surface of the embryo. When completed, it constitutes 
the internal membrane of the ovum; and from its inner surface there 
exudes, a liquid (liquor amnii) which is essential to the safety and fur- 
ther development of the embryo, — not by affording it nourishment, to 
any extent, but by the mechanical support and protection which it con- 
stantly maintains. The liquid consists of water, holding in solution a 
small quantity of albumen and salts. It is at first limpid, but, towards 
the end of pregnancy, it becomes of a higher specific gravity, and is 
often milky, or of a darker color, with numerous albuminous flakes. 
When the hue is greenish, or dark in shade, this is probably due to 
the escape of the contents of the bowel. The quantity of the liquid 
varies extremely, and that, too, without apparent cause ; and while its 
actual quantity may be said to augment during the whole period of 
gestation, it is generally admitted that, relatively to the size of the 
foetus, it increases during the first half of pregnancy, and diminishes 
from that time onwards. In addition to the protection of the foetus 



108 DEVELOPMENT OF THE OVUM. [CHAP. 

from shock, which must manifestly be exercised to the greatest advan- 
tage during the early months, the liquor amnii gives room for the 
movements of the foetus, which we cannot doubt to be essential to its 
proper development, and for changes in position or posture, in obedi- 
ence to the laws of gravity. It protects, also, the umbilical cord from 
pressure; and, during labor, prevents the walls of the contracting 
uterus from pressing prematurely on the surface of the child, while it 
safely and expeditiously effects the mechanical dilatation of the os. 
Finally, omitting, for the present, the possibility of its being a source 
of nutriment, it is of great assistance to the accoucheur, — preventing 
the firm contraction of the uterus upon the child, and so facilitating, in 
many ways, both manual and instrumental operations. 

External to the amnion, the interval between it and the chorion is 
occupied by a soft and gelatinous substance, to which Velpeau gave 
the name of vitriform body ; and imbedded in which is found the re- 
mains of the umbilical vesicle. The long pedicle of the umbilical vesi- 
cle penetrates the cord, by an aperture in its sheath. The closure of 
the amnionic cavity, the formation of the allantois, and the connection 
thus ultimately established between the embryo and the exterior of the 
ovum, complete the essential parts of the ovum. The latter now 
consists — 

a. Of the Embryo. 

b. Of the Liquor Amnii, in which it is suspended. 

c. Of the membrane of the Amnion, which is the internal membrane 
of the ovum, is continuous with the external surface of the embryo, 
and forms a sheath to the umbilical cord. The pedicle of the umbili- 
cal vesicle passes through an aperture in this sheath. 

d. Of the Urachus or pedicle of the Allantois, and other parts which, 
together, form the Umbilical Cord. 

e. Of a space between the amnion and the chorion, containing the 
remains of the vitriform fluid and of the Umbilical Vesicle. 

/. Of the Chorion, — the external envelope of the ovum. 

These parts, although deriving, no doubt, the supply of material 
necessary for their growth from the parent, are strictly of embryonic 
origin, or spring from parts which take their rise in connection with 
the embryo or the peripheral membranes of the ovum. Other struc- 
tures, however, are simultaneously developed, which may be regarded 
as in whole or in part maternal. 

The outermost of the three coverings of the ovum, one which, ac- 
cording to every hypothesis hitherto advanced, must be looked upon as 
purely maternal in its origin, is the decidua. The theory originally 
propounded by Hunter, and adopted by the great bulk of physiologists 
of the early part of the present century was simply this : The conges- 
tion and excitement coincident with impregnation, caused, on the inner 
surface of the uterus an exudation of a new formation of the nature of 
coagulable lymph, which closed the orifices of the Fallopian tubes, 
leaving only one opening, corresponding to the internal os. The ovum, 
on its arrival in the uterine cavity, was assumed to push this mem- 



VI.] 



FORMATION OF THE DECIDUA, 



109 




Diagram, showing Hunter's 
theory as to the formation of 
decidua. 



brane before it, so that the decidua became naturally divided into two 
parts, that which adhered to the uterine surface 
[decidua vera, a), and that which invested the 
ovum (decidua reflexa, b). Subsequent ob- 
servation having shown that a portion of 
membrane, identical in its structure with 
these, was found behind the ovum, — between 
it and the uterine wall, — this was regarded as 
a formation subsequent to the arrival of the 
ovum, and was named the decidua serotina. 
This theory owed its general acceptance to 
the fact, that it afforded an explanation of 
what had frequently been observed in abor- 
tions — that the complete ovum was found to 
be inclosed in a pouch, which was shed from 
the uterus, and which thus derived its name. 
The view universally adopted by modern 
physiologists is, however, quite different from this. 

We have already seen in our notice of the mucous membrane of the 
uterus, as observed in women who have died during menstruation, that 
it is at these periods greatly hypertrophied and congested, and, in con- 
sequence, thrown into convolutions. (See Fig. 47.) Up to a certain 
point the changes after impregnation are identical with those which 
accompany the menstrual molimen. According to Robin, the colum- 
nar and ciliated epithelium is partly exchanged, during the progress 
of pregnancy, for the tessellated variety, and partly desquamated. 
Sharpey and Weber found that the decidua vera was, allowing for the 
changes above mentioned, identical in structure with the mucous mem- 
brane of the uterus ; and, especially, that the characteristic tubular 
glands were abundant, and much more distinct than in the unimpreg- 
nated condition. By others, the orifices of the Fallopian tubes were 
found to be free. As regards the decidua reflexa, greater difficulties 
had to be surmounted. If this portion of the membrane be examined 
at an advanced period of pregnancy, it is found to be thin and trans- 
parent, if indeed it can be separated from the decidua vera; and it 
then presents no trace whatever of the tubular glands. At an earlier 
period, the glands are found to be absent in the central or more promi- 
nent portion only, becoming more distinct, however, as we approach 
its point of contact with the decidua vera. In fact, we may assume, 
with Coste, that the views of Bischoff are, on this subject, incorrect, 
and that, on its first formation, the decidua reflexa is identical in its 
structure with the decidua vera. All this points irresistibly to the 
conclusion that the decidua is nothing else than the uterine mucous 
membrane, altered to suit the requirements of the case. 

The main difficulty which, on this view, will suggest itself to the 
student of physiology, is to account for the manner in which the ovum 
gets behind the mucous membrane. Here we must be content with 
theory; but it is a theory founded directly on the facts which modern 
physiology has revealed, and certainly preferable to that of Hunter, 
more especially as accounting for the existence of the decidua serotina. 



110 



DEVELOPMENT OF THE OVUM 



[CHAP. 




Fig. 59. 

I 



IHi 





Formation of clecidua; first stage. 



The ovum, on its arrival in the uterine cavity, is for a certain time 
free from all adhesion. Probably, it becomes arrested in one of the 

sulci between the convolutions into 
which the mucous membrane is 
thrown, and there it contracts ad- 
hesions, at the point where the 
placenta will presently be formed. 
On either side of it, there now rise 
projections of the mucous mem- 
brane (Fig. 59), as we have seen 
to occur in the formation of the 
amnion, and in that of the organs 
of special sense: the folds meet in the centre, and the evolution is com- 
plete, a (Fig. 60) being the decidua reflexa, b the decidua vera, and c 
the decidua serotina. The villi, which at this time are abundantly de- 
veloped on the surface of the 
ovum, are assumed by some 
to be received into the ori- 
fices of the uterine glands, 
and, indeed, Sharpey actu- 
ally found this to take place 
in the case of the bitch. The 
simple fact of extra-uterine 
pregnancy seems, however, 
sufficient to show that, al- 
though this may occur, it is 
by no means essential as a 
step in development. But, 
whatever view we may be inclined to take of the theory, the facts are 
these: if we open the uterus of a woman, about the fifth week of preg- 
nancy, we find, almost certainly, a tumor in the neighborhood of the 
fundus, and projecting into the cavity of the uterus. The Fallopian 
tubes are open, and the membrane which covers the tumor is continu- 
ous, and identical in structure, with that which lines the uterine cavity, 
the glands being probably more distinct near its base. The tumor, on 
being incised, discloses a cavity containing an ovum. All this seems 
to indicate that the modern theory is, at least, more likely to be correct 
than any hitherto advanced. 

If, in the course of such an examination as has just been indicated, 
the cavity be carefully opened, and a flap turned down, the ovum, quite 
uninjured, may then be observed, sometimes bathed in blood when 
bloodvessels have been injured. Its external surface will be seen 
bristling with villi, and on the inner surface of the everted flap, small 
depressions or lacunae may be noticed, into which the villi dip, and by 
means of which, no doubt, material is obtained for the time from the 
circulation of the mother. If, again, we cautiously remove the ovum 
and wash out the cavity, we shall find that the lacunse on the side of 
the decidua serotina are much deeper and more numerous. This marks 
the place at which the placenta is about to form. 

If we look again at Fig. 61, we may observe that in the most pro- 




Formation of decidua completed. 



VI.] 



THE UMBILICAL CORD. 



Ill 



Fig. 61. 



jecting part of the ovum, which is the centre of the everted flap, the 
membrane has become thin and exsanguine; and here, even at this 
early period, we would probably look in vain for the tubular glands. 
This is the commencement of another and an important change which 
goes on, pari passu, with the develop- 
ment of the placenta. Those villi of 
the chorion which pass towards the cle- 
cidua serotina are more and more de- 
veloped, and become imbedded in the 
latter, the two together forming the 
placenta, an organ to be immediately 
described. So soon as this new con- 
nection is thoroughly established, the 



villi over 



the remaining surface of tl 



ic 




Flap of decidua reflexa turned down, dis- 
closing the ovum. 



ovum diminish or cease to grow in the 
same proportion; and, as the ovum ex- 
tends, they become thin and scattered 
over that side of the chorion which is 
most distant from the placenta, and are 
ultimately absorbed, the external sur- 
face of the chorion being then perfectly smooth. With this, the decidua 
reflexa loses its vascularity, the vessels becoming obliterated from the 
centre of the projecting part towards the circumference. As development 
progresses, the ovum steadily increases in size, and the cavity which 
exists between the two layers of decidua becomes, in consequence of this, 
encroached upon, until, about the third month, the two come into con- 
tact, and the whole of the uterine cavity is then occupied by the foetus 
and its membranes. It is impossible after this stage to distinguish or 
separate the decidua vera from the decidua reflexa, which has led Dr. 
A. Farre to think it probable that the decidua reflexa, after becoming 
extremely attenuated, ultimately disappears entirely. We do not doubt, 
however, that although it may become very thin, it may with care be 
traced. 

Let us now turn again to the interior of the ovum, the essential 
parts of which were completed by the formation of the allantois. The 
elongation of the pedicle of the allantois, and the obliteration of its 
cavity takes place with great rapidity, and, at the same time, the cord 
becomes greatly increased in length. From this period onwards, the 
Umbilical Cord consists of the following parts : the amnionic sheath, 
which entirely surrounds it, save at one point, where a small slit gives 
egress to the pedicle of the shrunken umbilical vesicle ; the two umbilical 
arteries and the umbilical vein, which form the greater portion of the 
bulk of the cord ; that portion of the pedicle of the umbilical vesicle, 
which extends from the umbilicus to the point of exit; and lastly, the 
remains of the pedicle of the allantois. By means of the villi of the 
chorion, acting, as Professor Owen has observed, like the spongioles of 
a plant, nutriment is extracted from the maternal soil in which it is 
imbedded, each vascular tuft being, as it were, an independent centre 
of respiration and nutrition. But, with the complete establishment of 
the umbilical communication — for it cannot as yet be termed a "cord" 
— these functions become localized in the human race, and there now 



112 DEVELOPMENT OF THE OVUM. [CHAP. 

begins to form, at the point, probably, where the allantois first touched 
the wall of the ovum, an important special organ of connection, the 
Placenta, in which externally the umbilical cord terminates. The 
Umbilical Cord, being composed of the elements above detailed, con- 
ducts the foetal blood from the bifurcation of the abdominal aorta to 
the placenta by its two arteries, and brings back the same blood by 
means of its single vein, it having meanwhile undergone certain changes. 
The obliteration of the umbilical vesicle soon admits of the closure of 
the aperture alluded to, and thus reduces the contents of the cord to 
the vessels above mentioned, and the loop of bowel which still protrudes 
by the umbilical orifice. This communication between child and pla- 
centa varies considerably in length. At first, it is short, and is also 
thick in proportion to the size of the ventral aperture, but soon becomes 
considerably elongated. Even at. the termination of pregnancy, how- 
ever, great varieties are observed, it being in some instances no more 
than a few inches in length, and in others extending to five feet or even 
more. Its average length, at the full time, may be assumed to be 
somewhere about twenty inches. The vessels, which are devoid of 
valves, and which give off no branches in the cord, are disposed in 
regard to each other, in a manner somewhat peculiar. Firmly bound 
together by a tenacious substance called the gelatin of Wharton, the 
quantity of which determines in a great measure the thickness of the 
cord, the vessels are invariably twisted like the handle of a basket. 
This does not take place in an irregular manner; on the contrary the 
twist is, nine times out of ten, from right to left, and, invariably, the 
vein forms as it were a centre or axis, around which the arteries are 
arranged in an irregularly spiral form. This twisting, which has been 
observed as early as the second month, is supposed to depend partly 
upon the movements of the foetus, and partly upon a more rapid growth 
of the arteries than of the other tissues of the cord. On an average, 
the cord is about the thickness of the little finger. Many anomalies 
have been observed in its formation. One artery; three arteries; and 
even three veins have been met with, without anything untoward hav- 
ing occurred, in any stage of the case, in the course of pregnancy. 

When the cord is too long, knots have frequently been observed 
upon it. These are, doubtless, due to the movements of the foetus, and 
are much more likely to occur if, along with great length of the cord, 
there is an excess of the liquor amnii. It is easy to understand how, 
under such circumstances, the foetus might float through a large loop, 
and a knot be the immediate or ultimate result. It is conceivable that 
danger might arise from this, in the course of labor, should any me- 
chanical complication tend to draw the knot tighter; but all experience 
seems to show, that these knots are not to be looked upon as dangers, 
unless under such very exceptional circumstances. 

The cord is of very considerable strength, as a general rule, as is 
shown in cases where: — often in error — considerable force is brought to 
bear upon it, in attempts to remove the placenta when this organ is 
retained. At other times, a very moderate tension will suffice to break 
it. It is firmly adherent, at its foetal extremity, to the abdominal walls 
of the child, and, at the placenta, it is found to be intimately con- 



VI.] THE PLACENTA. 113 

nectecl with the tissues of the chorion. Externally, its connection with 
the amnionic sheath is of slighter character, and this is more particu- 
larly to be observed near the placenta, where the amnion often passes 
off from it near to the point of its insertion, and thus forms a sort of 
infundibuliform investment, which has been noticed by many authors. 
Nerves and lymphatics have been described as appertaining to the 
umbilical cord ; but these, if present, are so difficult to trace that their 
existence is very generally doubted. 

The Placenta. — The ovum is, as we have seen, supplied with nutri- 
ment, in the first instance, directly from the contents of the umbilical 
vesicle, through the channel of communication which exists between it 
and the intestinal canal ; subsequently, in all probability, through the 
medium of the omphalo-mesenteric circulation ; and, at a still later 
period, before the formation of the allantois, through the villi of the 
chorion, by imbibition. When, through the agency of the allantois, 
the umbilical vessels have been projected to the walls of the ovum, a 
more direct means of communication is at once established. In the 
lowest Mammalia, which are hence called ^non -placental," no further 
change takes place in this respect — the whole periphery of the chorion 
exchanging elements with the maternal parts, as in the early human 
ovum — until the period of birth. In many of the higher Mammalia, 
as in the Ruminants, certain portions of the surface of the ovum con- 
tract with the superimposed maternal parts more intimate adhesions, 
while other parts become comparatively deprived of their villi. An 
increase of tissue at these points gives rise to the formation of " cotyle- 
dons," which may be looked upon as so many miniature placentae, the 
structure of the uterus, forming the cotyledons, being in these animals 
permanent. Many other and interesting varieties arc observed, among 
which we may mention the diffused placenta of the mare and pig, and 
the zonal placenta of the Carnivora. In man, however, and the higher 
orders, the mass is confluent and concentrated at one spot, and thus 
forms the single connective organ which is known as the Placenta. 

The disappearance of the villi over the remaining portion of the sur- 
face of the chorion, concentrates within the new organ the functions of 
nutrition and respiration, which it has thenceforth to discharge. A 
study of its structure is of peculiar interest to the obstetrician, as any 
diseased or other condition which may affect the due performance of 
its functions, must necessarily exercise an important influence on the 
healthy and normal development of the embryo. In many of the 
animals in whom a placenta exists, that portion which is derived from 
the ovum may be readily separated from the part which is of maternal 
origin ; but, in the human placenta, no such separation is in any way 
possible, so intimately are the two elements incorporated together. We 
must, nevertheless, look upon the placenta as composed originally of 
two distinct parts or layers, which are accordingly named the matwnal 
and foetal portions of the placenta. 

The maternal portion is developed out of that part of the uterine 
mucous membrane to which the ovum attached itself on its arrival in 
the uterus. In other words, it is the decidua serotina. No sooner has 
its formation commenced, than the bloodvessels in the corresponding 

8 



114 DEVELOPMENT OF THE OVUM. [CHAP. 

region of the uterus become notably enlarged, the arteries retaining 
their characteristic spiral form, while the diameter of the venous trunks 
becomes so much increased, that they are now called sinuses. In the 
earlier stages of formation, the maternal and foetal vessels are easily 
seen to run in distinct structures, which may be separated artificially 
from one another, without rupture of any of the vessels. But, as the 
placenta becomes more consolidated, the interweaving of the two sets of 
structures becomes more intimate, by the thinning out of the interven- 
ing material, while the villous ramification of the foetal part, becoming 
more and more extended, is accompanied by a corresponding inflection 
of the maternal structure and vessels over every part of the villous 
surface; so that, at last, there is produced so complete a combination 
or interlacing of the two as to make it quite impossible to separate 
them, or even to distinguish accurately the confines between the struc- 
ture which was originally foetal and villous, and that which was ma- 
ternal, or decidual and venous. Numerous observations have proved 
this, but none more distinctly than the experiments of Bonami, to 
which we shall immediately refer. Before doing so, however, it is 
necessary to observe that, on separating a placenta from its uterine 
attachment by cautiously drawing the parts asunder, it becomes obvious 
that a special tissue intervenes. This has been described as separating 
into two thin gelatinous layers, consisting when in situ of interlacing 
lamellae, adhering at certain points only of their surface, and thus 
forming cells which may be shown on gently drawing the parts asunder. 
This is the interplaeental or inter liter o -placental tissue. 

Bonami demonstrated so far the structure of the placenta by colored 
injections as follows: He injected — 

1st. Red, from the iliac and ovarian veins : 

2d. Blue, from the uterine arteries : 

3d. White, from the umbilical vein : 

4th. Yellow, from one umbilical artery, the other being tied to pre- 
vent the regurgitation from the anastomosis, which would otherwise 
have occurred. 

Careful observation and dissection then disclosed the following facts : 
that numerous red vessels were visible through the amnion on the foetal 
surface of the placenta; that red and blue vessels, the former straight 
and the latter spiral, were seen to pass in great numbers through the 
utero-placen tal tissue, and to penetrate the placenta; and, finally, that 
a white and yellow network was distinctly seen on the uterine surface of 
the placenta. As no escape of the injected fluids had taken place into 
the intermediate tissues, the facts speak for themselves. 

Before proceeding to consider the more minute structure of the pla- 
centa, some general description of the physical characters of the mature 
organ may here be given. On its removal from the body, it is found 
to be a soft spongy mass, about twenty ounces in weight, and seven and 
a half inches in its greatest width. These are, of course, average di- 
mensions, as it varies greatly in size; and, on the same principle, it is 
described as being three-fourths of an inch thick in the centre, and one- 
eighth to one-fourth of an inch at the margin. It is usually somewhat 
oval in form, and the umbilical cord is inserted in the centre of its 



VI.] 



STRUCTURE OF THE PLACENTA. 



115 



foetal surface. It may be situated at any portion of the uterine surface, 
even over the os, but its usual site is the neighborhood of the fundus. 
It presents for observation an internal or foetal, and an external or 
uterine surface. 

The internal surface (Fig. 62) is smooth, and is covered by the am- 
nion, through which the vessels are distinctly seen to divide and sub- 



Fig. 62. 




Foetal surface of the placenta. 

divide before plunging into the tissue beneath. The external or uterine 
surface (Fig. 63) is very different from the former. It is slightly 
rough on the surface, giving a peculiar granular impression to the 
finger, very familiar to every obstetrician. It is, moreover, divided 
into irregular lobes, which may be easily torn or separated from each 
other. Indeed, examined from this side, the substance of the pla- 
centa may be said to be brittle. This surface is covered, as has been 
shown, by a thin layer of utero-placental tissue, through which, with 
some care, and by floating the placenta in water, the oblique passage of 
the veins from the uterus may be detected. The margin is continuous 
throughout with the membranes; the foetal portion with the chorion, 
and the maternal with the decidua. 

Peculiarities in the structure of the placenta, and in the manner of 
its connection with the umbilical cord, are not very uncommon. What 
is known as battledore placenta is one of the most common of these, the 
cord being then attached, not to the centre, but to the margin of the 
placenta, giving it something of the form from which it has derived its 
name. In other cases, although much more rarely, small lobes or 
cotyledons are found detached from the general mass, as in a case fig- 



116 



DEVELOPMENT OF THE OVUM 



[CHAP. 



ured by Dubois; while in twin cases certain modifications are observed 
which are essential to the dual development, but which will fall more 
naturally to be considered under the section relating to plural preg- 
nancy. 

The structure of the placenta being thus complicated, it is not to be 
wondered at that great difficulties have been encountered in determin- 
ing what is the nature of the communication which there takes place 
between the foetal and maternal circulating systems. An opinion long 
obtained that there was a direct commingling of the two currents, and 
that blood passed from the uterine arteries directly to the foetus, and, 



Fig. 63. 




Maternal surface of the placenta. 



after there yielding a portion of its vital constituents, returned again by 
the uterine veins. The earliest attempts at injection being no doubt 
unskilfully executed, seem to have encouraged this belief. Modern 
physiologists have long since dispelled this illusion, and the experiments 
of Bonami above cited demonstrate, along with others, that there is a 
maternal and a foetal circulation, each being distinct from the other as 
regards continuity of current down to its uttermost conduits. The 
vessels of the two systems are, however, in intimate contact throughout, 
as is made obvious at once by anatomical demonstration, and by a 
knowledge <of the physiological necessities of the case. What, then, is 



VI.] 



CIRCULATION IN THE PLACENTA. 



117 



the nature of the contact which permits of an interchange of material 
between the two? 

In attempting to answer this question, and to describe the minute 
structure of the placenta, it must be admitted that there are still many 
points in regard to which differences of opinion exist, and some diffi- 
culties which have yet to be explained. To enter upon a full consid- 
eration of these would ill accord with the expressed object of this work, 
but a general view of the case, as adopted by the best authorities, may 
here be briefly epitomized. The vessels which are seen to pass through 
the utero-placental tissues are, with an important exception to be noticed 
afterwards, of two kinds, arteries and veins. The former, the " curl- 
ing arteries'' of the uterus, as they are generally called, are of mod- 
erate size; they do not anastomose much, nor are their ramifications 
very numerous, and they retain, within the placenta, in a certain de- 
gree, their spiral disposition. The veins are somewhat larger, straight 

Fig. 64. 




Section of the placenta. 

in their direction, and with numerous anastomoses. Some have sup- 
posed that the connection between these veins and arteries was of the 
nature of a simple capillary circulation; but the researches of Eeid, 
Weber, and Goodsir, have shown that their connection is of a special 
character, and offers the strongest possible contrast to a capillary sys- 
tem. According to them, the blood is conducted by the curling arte- 
ries into large irregular cells or sinuses, the walls of which are thin, and 
composed of the lining membrane of the maternal vascular system 
only. These sinuses communicate freely with each other, and from 
them the blood is returned to the uterus through the veins which are 
seen to pass through the utero-placental tissue. In fact, a considerable 



118 



DEVELOPMENT OF THE OVUM 



[CHAP. 



portion of the bulk of the placenta, when the organ is replete with 
blood, is said to be composed of a great venous cavity, which dips so 
deeply into the chorion as to attain its foetal surface, but which is more 
distinctly seen in the tissue of the decidua. A large coronary vein has 
been described by Jacquemier and Meckel as existing near the margin 
of the placenta. It is, they say, rarely complete, but presents in its 
course frequent interruptions, where the continuity is maintained by 
subdivision and anastomosis: but as their observations on the subject 
have not been confirmed by recent research, we may assume that the 
existence of such an arrangement is doubtful, certainly not constant. It 
is proper to add that the presence of a great venous cavity within the 
placenta has quite recently been seriously called in question. 

On the foetal side, the vessels, on reaching the placenta, divide at 
once into large branches which are distinctly seen through the amnion. 
If this membrane be detached, which may easily be effected, as shown 
in the upper part of Fig. 62, both arteries and veins are observed to 
divide on the surface of the chorion. They then subdivide again and 
again, always dichotomously, and plunge into the thickness of the lobes. 
Here the arteries communicate freely with each other, so that if we in- 
ject one umbilical artery, the injection will return by the other. If, 
however, we tie the other, a successful injection will return into the 
umbilical vein, while the color of the injection will be observed on the 
uterine surface of the placenta. If we trace the arteries to their ulti- 
mate ramifications, we find that they are divided into innumerable tufts, 
fringes, or villi, which form in fact the bulk of the foetal placenta. 
Each tuft is occupied by one or more capillary loops, and the current, 
after passing through these loops, returns by the affluent canals, form- 
ing by their union the umbilical vein. The vessels of this capillary 
system differ from other capillaries in their greater size, their calibre 
being such as to admit of several blood-corpuscles passing abreast of 
each other. Throughout the whole placenta, the villi are found to 
project in the form of fringes into the placental sinuses, or, in other 
words, into the large venous cavity which is formed in the placenta 

Fig. 65. 




Fcetal villi of the placenta. 



by the union of these sinuses. Each fringe is thus bathed in maternal 
blood, and the foetal blood passing through each loop parts with its 
carbonic acid and receives oxygen in exchange, precisely as occurs in 
the branchiae of aquatic animals. And, further, as was first shown by 



VI.] 



VILLI OF THE PLACENTA. 



119 



Reid, a certain number of the foetal villi pass through the placenta, 
and dip directly into the larger sinuses of the uterus itself. 

Reid believed further, and his view 
is very generally accepted, that each 
tuft, in projecting into the placental 
cavity, pushed before it the lining mem- 
brane of this cavity, so that each foetal 
villus had a special maternal investment. 
It is to be observed, however, that among 
English physiologists, Dr. A. Farre 
combats this view, and that both Coste 
and Robin are opposed to it. They be- 
lieve that the walls of the uterine vessels 
are eroded and perforated by the villi, 
so that the walls of the latter are in di- 
rect contact with the blood of the mother. 
It will be observed, however, that either 
view of the case is sufficient to confirm 
the views first enunciated by the Hunt- 
ers, that there is no commingling of the 
two systems. The accompanying illus- 
trations refer to the arrangement and 
structure of the foetal 



Villi. 




Ultimate foetal villus, highly magnified. 



In Fig. 
6Q, the cellular covering which covers 
the villus is shown, except at its distal 
portion, where it has been removed to 
show the looped vessels. 

It must be remembered that the oxygenation of the foetal blood is 
not the only function of the placenta; but that through this channel 
also, material is supplied for the building up of the foetal tissues, and 
effete matter is removed. The observations of Goodsir on this point, 
which are of the greatest possible interest, are corroborative of the views 
of Reid. These will be noticed when we come to speak of the nutrition 
of the foetus. 

The formation of the placenta commences in the latter part of the 
second month, and within a few weeks it acquires its essential charac- 
teristics. Small bloodvessels, for the special nourishment of the organ, 
pass from the uterus ; but neither nerves nor lymphatics have been, as 
yet, satisfactorily traced. It is proper to add, that although the view 
which has been given of the structure of the placenta is that almost 
universally entertained, some physiologists have denied the existence 
of a sinus system. The names of Velpeau, Radford, Ramsbotham, 
and Madge may be mentioned as holding more or less confidently the 
latter view ; but of late the contribution in refutation of the Hunterian 
theory which has attracted most attention is the Essay which Dr. 
Braxton Hicks presented to the Obstetrical Society in 1873. 



120 DEVELOPMENT OF THE EMBRYO AND FOETUS. [CHAP. 



CHAPTER VII. 

DEVELOPMENT OF THE EMBRYO AND FCETUS. 

DEMONSTRATION OF EMBRYONIC STRUCTURES — CHARACTERISTICS AND DEVELOP- 
MENT OF THE FCETUS AT THE TERMINATION OF EACH MONTH OF PREGNANCY, 
FROM THE THIRD ONWARDS — DIMENSIONS OF MATURE CHILDREN — OF THE 
PRESENTATION AND ATTITUDE OF THE CHILD IN THE WOMB — CAUSES OF 
CRANIAL PRESENTATION: THEORIES OF "PHYSICAL GRAVITATION," " VOLI- 
TION, " AND "REFLEX ACTION" — THE FCETAL CRANIUM: SUTURES: FONTA- 
NELLES : DIAMETERS — DEFINITION OF THE TERM "VERTEX" — FUNCTIONS OF 
THE FCETUS : CIRCULATION : RESPIRATION : NUTRITION : SECRETION. 

The term Foetus is, according to usage, not applicable to the product 
of conception, until the termination of the third month of gestation. 
Till then it is termed the Embryo. A study of the formation of the 
various embryonic structures is a subject which, in so far as human 
development is concerned, is beset with many difficulties. Viewed, 
however, in the light which comparative physiology has thrown upon 
it, our knowledge of the various organs of which the individual is 
composed, and of their growth from primal elements, may be considered 
as tolerably complete. The opportunities which arise of examining 
the bodies of women who die in the earliest stages of pregnancy are so 
few, that a very peculiar interest attaches to such reliable descriptions 
and representations as have hitherto been made. Among all these, 
none perhaps have received more unqualified commendation than the 
well-known drawings of Coste, from which the representations which 
follow have chiefly been taken. To attempt a demonstration, or even 
a narrative of the development of individual organs, is only suitable to 
a systematic treatise on Embryology. A very superficial description 
will serve our purpose here, and may suffice to show, more clearly than 
is possible by any means other than actual dissection, the relations 
which the various parts of the ovum bear to each other, and to the 
maternal structures with which they are in contact. 

The accompanying representation of the product of an abortion about 
the twenty-fifth to the twenty-eighth day, shows the embryo and its 
membranes partly dissected, and magnified about seven times and a 
half. The Chorion, which has been opened in its whole extent, is 
recognized by its villi externally, and the numerous bloodvessels on its 
internal surface. Above, and to the left, is seen the umbilical vesicle, 
w r ith the branches of the omphalo-mesenteric vessels coursing upon it. 
It lies, as has already been shown, between the chorion and the amnion, 
and its long narrow r pedicle bearing the vessels is seen to pass into the 
umbilical cord, and, finally, to terminate at the summit of the single 



VII.] 



STRUCTURE OF THE EMBRYO. 



121 



curve which marks the commencement of the intestinal convolutions. 
The right omphalo-mesenteric artery is close below the intestinal canal, 
and included in the rudimentary mesentery. The left omphalo-mesen- 
teric vein (v) is passing towards where the stomach is beginning to 



Fie. 67. 




Ovum opened, and embryo partly dissected. 



develop, to discharge itself into the common trunk of the umbilical 
veins. This is the commencing vena portse. The amnion (m wi) has 
been freely opened to allow the embryo to escape, the caudal extremity 
being still within its cavity. The manner in which it is reflected to 
form the sheath of the umbilical cord is very clearly shown. The 
umbilical cord is opened in its whole extent to show its contents, in- 
cluding the canal of the urachus (pedicle of the allantois), which 
extends from the caudal extremity of the alimentary canal, closely ac- 
companied by the umbilical vessels, and terminates at w in a cul-de-sac. 
On either side are the umbilical arteries and veins, the arteries spring- 
ing from the lower part of the aorta, and the veins passing upwards, to 
unite before entering the liver and mix their contents with the general 
circulation, at the point of confluence (o), beneath the heart. The vein 
of the left side, which may be observed passing through the centre of 



122 



DEVELOPMENT OF THE EMBRYO AND FOETUS. [CHAP. 



Fig. 68. 



the mesentery, is the permanent one, and is already much larger than 
its fellow of the right side, which has been cut across at p p. The 
heart (h), with its four cavities and the aortic bulb, is separated from 
the liver by an imperfect diaphragm. The Wolffian 
body of the right side (w) is shown passing from 
the heart to the inferior extremity of the intestine. 
Along its outer margin runs its excretory duct, 
which opens, along with its fellow of the other 
side, into the cloaca behind the rectum. The 
greater relative size of the cephalic extremity of 
the embryo is a striking peculiarity which at 
once attracts attention. The rudimentary eye 
(a) is remarkable, chiefly in respect of its lateral 
position. In front of it is the right nasal fossa, 
and below it, at e, is the earliest trace of the in- 
ternal ear. The large bucco-nasal cavity, with 
the three branchial arches beneath it, also attract 
special notice. 

Fig. 68 shows the same embryo magnified eleven 
times, carefully dissected, and seen from before. A 
portion of the intestinal convolution and of the 
mesentery has been removed, along with the an- 
terior thoracic and abdominal walls, and the um- 
bilical cord, so as to bring into view the most of 
the Wolffian bodies on each side, and the heart. 

This representation shows more clearly the 
lateral position of the eyes (a), and the distance 
between the nasal fossa? (/), which are seen to 
communicate with the buccal cavity by a simple 
furrow. Between a and / are the rudiments of 
the superior maxillary bones. There is complete 
absence of all trace of palate. The position of 
the auricles, ventricles, and aorta, and the relation 
which these parts bear to each other at this age, 
are also more obvious from this point of view. 
Hidden to some extent by the heart, and sepa- 
rated from it by an incomplete diaphragm, is the 
liver (I), which is of equal size on the right and 
left side, and presents a fissure on its lower surface; it covers and con- 
ceals the stomach. The vessel which is seen in section within this 
fissure (m), is the common trunk of the umbilical veins. To the left, 
within the curve of the intestine (i), is the left omphalo-mesenteric vein 
(v), the one which, being permanent, ultimately becomes the vena 
porta?. Below the alimentary canal, and within the mesentery, is the 
right omphalo-mesenteric artery (o). 

Extending downwards from the lower surface of the liver to the 
caudal extremity of the embryo, are seen on either side the Wolffian 
bodies, with their excretory ducts close to their external borders. The 
white band running along their inner margin is the rudiment of the 
internal generative organs. Between these parts is the divided mesen- 



4 



The same embryo, further 
dissected. 



VII.] 



STRUCTURE OF THE EMBRYO. 



123 



Fig. 69. 



tery, connected inferiorly with the alimentary canal (i). Immediately 
below this, the transverse slit shows a section of the cavity of the ura- 
chus, while the vessels which along with it form the umbilical cord are 
seen to surround it, the veins being below the arte- 
ries. It will be observed that one vein is already 
smaller than the other, and would ultimately have 
become obliterated. The buds or rudiments of the 
superior and inferior extremities are quite distinct; 
p is the common orifice of the genito-urinary system. 

Fig. 69 shows the branchial apparatus, rudimen- 
tary lungs, stomach, and liver, from behind. Above, 
is the inferior maxilla, the two lateral halves of 
which have already united in the middle line. Be- 
tween this and the superior branchial arch is the 
rudiment of the tongue. From above downwards 
are the first, second, and third branchial arches, sepa- 
rated from each other by slits or apertures {branchice). 
Into the pharyngeal cavity which is thus exposed, 
the branchial apertures, the oesophagus, and the 
glottis open. The origin of the glottis is an oval 
eminence with a slit, which is indicated at b : c c are 
the rudimentary lungs pressed against the oesopha- 
gus, the right being lower than the left: (s) the 
stomach, at this period vertical in direction, and 
forming, with the oesophagus and alimentary canal, 
a nearly straight tube : ( I) the liver, formed on either 
side of two nearly equal lobes, with a large furrow 
accommodate the stomach. 

In Fig. 70 the heart is seen from behind. The 
preserved in order to show the relation, in size and position, which 
they bear to the heart, (a a) Auricles, the right being 
evidently more developed than the left, (v v) Ven- 
tricles, the left larger than the right. 




Posterior view of bran- 
chial apparatus, etc. 

between them to 



ungs have been 



The 



large vessel in the centre is the trunk common 




Posterior view of foetal 
heart. 



to the omphalo-mesenteric, umbilical, and azygos 
veins. That to the right in the figure is common 
to the superior azygos vein (superior cava of the adult), 
and the inferior of the right side; the smaller trunk 
to the left is common to the azygos, superior and in- 
ferior, of the left side. 

(ce) Section of oesophagus. 

The woman from whom the drawing (Fig. 71) was taken was, as 
may be inferred from the structure of the os and cervix, pluriparous. 
She committed suicide about the fortieth day of pregnancy, and her body 
was subsequently examined at the Morgue in Paris. The anterior 
wall of the uterus has been divided vertically in its whole length, and 
the uterus thus laid open. " The cavity of the uterus," says Coste, 
" was partly occupied by a sort of soft fluctuating tumor, caused by 
the presence of the ovum at this point. This tumor had externally all 
the appearance and the organization of the mucous membrane which 



124 



DEVELOPMENT OF THE EMBRYO AND FOETUS. [CHAP. 



lined the uterus in the rest of its extent, and was situated on its pos- 
terior surface in the space between the two Fallopian tubes. The 
tumor produced here by the presence of the ovum did not yet occupy 
the whole cavity of the uterus. About the lower third of this cavity 
was free, so that the interior of the uterus might be reached from the 
canal of the cervix without encountering any resistance. The internal 
orifices of the Fallopian tubes were, as well as that of the cervix, per- 
fectly permeable, which was proved in the clearest manner by the ob- 
servation of the orifice of the left tube, through which the ovum had 
passed on its way to the uterus." In order to demonstrate the struc- 
ture and relation of the parts, a circular incision was first made 
through the decidua reflexa, and the flap thus formed was turned down 
towards the internal os. On its inner or everted surface (d), the lacunae 



Fig. 71. 




Dissection of an ovum in situ, about the fortieth day. 

are seen, which have already been described as existing at this period 
of pregnancy for the reception of the villi of the chorion. The ovum 
itself was then opened by a crucial incision, and the flaps of the chorion 
(c c) turned aside, so as to show the amnion (a). Through the walls of 
the latter membrane, the embryo is seen floating freely in the liquor 



VII.] GROWTH OF THE FCETUS. 125 

amnii. The short and thick umbilical cord is observed passing from 
its ventral surface to that part of the surface of the chorion where the pla- 
centa would afterwards have been found. The situation of the umbili- 
cal vesicle in the cavity between the chorion and the amnion (a point 
which the student has occasionally some difficulty in understanding) 
is here very satisfactorily shown, and also the long pedicle which pene- 
trates the umbilical cord, and through which communication with the 
intestinal cavity of the embryo is still for a time kept up. The amnion 
is not yet of sufficient size to fill the cavity of the chorion, which still 
contains a portion of the vitriform substance (magma reticule of Vel- 
peau). This substance gradually disappears as the ovum increases in 
size, becomes compressed, and ultimately is reduced to a layer of ex- 
treme thinness when the amnion and chorion come into contact, when 
all but a trace of the umbilical vesicle disappears. 

After the development of the placenta is completed, and the villi of 
the free surface of the chorion have been absorbed (as some suppose, 
by a process of fatty degeneration), not only does the cavity between 
the chorion and the amnion disappear, but that which exists between 
the decidua vera and the decidua reflexa is also gradually encroached 
upon by the growth of the embryo. When these membranes finally 
adhere, that cavity, too, is obliterated; and now, for the first time, the ) 
product of conception may be said to occupy the whole cavity of the ^ 
uterus. These changes are completed in the course of the third month. 

At this period, the foetus measures, in length, from five to six inches, 
and weighs about four ounces; and the development of its limbs and 
other parts has advanced to such an extent, that the external parts 
may be said to be completely formed. The head, although still, rela- 
tively, of great size, is so in a much less degree than at an earlier 
period. The various cavities are completely closed. The formation 
of the palate, and the completion of the superior maxillary bones, has 
divided the bucco-nasal cavity. The branchial arches have disappeared 
as early as the fifth week, with the exception of one fissure which has 
developed into the external ear. The umbilical cord is already longer 
than the embryo, has assumed its characteristic spiral form, and is at- 
tached considerably below the middle point of the vertical measure- 
ment of the child. Previous to this, a loop of intestine occupied a 
portion of the cord, but this is now included, by contraction of the 
umbilicus, within the abdominal cavity. When that condition is per- 
manent, umbilical hernia is the result. The globe of the eye is seen 
through the eyelids, and the pupillary membrane may be seen filling 
up the aperture of the iris. The nails have commenced to form, but 
are very thin, and almost membranous. The sexes are distinct. 

At the end of the fourth month 1 the length of the foetus will be found 
to have increased to from 6J to 7| inches, and its weight to nearly 9 V 
ounces on an average. On examining the head, the fontanelles are 
found to be of great size, and the sutures apart. Hair makes its ap- 
pearance on the scalp, in the form of a slight down, which may also 



1 The expression, "at the month," is very loosely employed by many wri- 
ters. When weeks are not mentioned, it is used in this work as meaning the com- 
pletion of the calendar month of the pregnancy. 



12G DEVELOPMENT OF THE EMBRYO AND FCETUS. [CHAP. 

be noticed, in a still more delicate form, on the general surface. Fat 
begins to be deposited in the subcutaneous tissue. The muscular 
movements are brisk, although they may not yet have been recognized 
by the mother ; and, in abortions which take place at this epoch, the 
movements are not only vigorous at the moment of birth, but may 
continue for several hours afterwards. 

With the completion of the fifth month, the length of the body will 

V usually be found to have increased to from 8 to 10 inches, and its 
weight to from 10 to 12 ounces, or even more. 

At six months, it is from 11 to 12J inches, and weighs something 

' more than a pound avoirdupois. The growth of the hair has consider- 
ably advanced, and, in addition to that on the scalp, the eyebrows and 
eyelashes are also beginning to form. On the surface of the body, the 
cutaneous structure now becomes more distinct, and the cutis vera and 
epidermis may usually, on careful dissection, be separated. The invari- 
able wrinkling of the surface is the result of the minute quantity of 
subcutaneous cellular tissue which is developed up to this time, in pro- 
portion to the other structures. In the male, the scrotum is very small 
and empty. The nails are already solid. 

\y In the course of the seventh month the foetus is from 12J to 14 inches 
in length. The bulk becomes, from this period, steadily increased, by 
the deposition of subcutaneous cellular tissue, and the development of 
various organs ; but as the extent of this varies very greatly in differ- 
ent cases, it is difficult to say what should be stated as the average 
weight of this period. The bones of the cranium, — in which the pro- 
cess of ossification has already considerably advanced, — become more 
prominent, and the intervals between them less. It is usually said, 
that about this time the pupillary membrane disappears ; but this is a 
question in regard to which very considerable discrepancy of opinion 
has arisen. Velpeau denied the existence of the membrane in the 
human species at any period, but the opinion usually entertained in 
regard to this point, is that which we have mentioned, — that it exists 
during pregnancy, up to the termination of the seventh month, and 
then disappears. More modern observations have, however, shown 
that it is incorrect to suppose that this membrane is lost at the time 
mentioned, but that it loses its vascularity in a great measure, and is 
so transparent that great difficulty is experienced in its demonstration. 
"In every instance/' says Mr. Jacob, 1 "where I have made the exami- 
nation, I have found the membrana pupillaris existing, in a greater or 
less degree of perfection, in the newborn infant, — frequently perfect, 
without the smallest breach, sometimes presenting ragged apertures in 
several places, and, in other instances, nothing existing but a remnant 
hanging across the pupil like a cobweb. I have even succeeded in in- 
jecting a single vessel in the membrana 'pupillaris of the ninth month." 
The eyelids now commence to open, and the testicles to descend in the 
scrotum . 

By the end of the eighth month, the increase in the bulk of the child 
and its general plumpness become very obvious, and this is shown still 

1 Cyclopaedia of Anatomy and Physiology. Art. " Eye." 



VII.] THE FCETUS IN UTERO. 127 

more clearly by taking its weight and measurement as before, when it 
will be found that whereas the longitudinal measurement has not in- 
creased beyond 17 inches, and is probably less, its weight will have 
reached 4 to 5J pounds. The skin is now red in color, is no longer 
wrinkled, and is covered with down. Upon its surface is observed, in 
greater or less quantity, little masses of curdy or sebaceous matter, — 
a substance which is not of new formation, although it has become 
much more abundant. It may be noticed as early as the fifth month. 
The scrotum now contains one testicle, usually that of the left side. 
v On the birth of the child at the termination of pregnancy, it will be 
'found to measure from 19 to 24 inches, and to weigh about 100 to 130 
ounces (say, on an average, about 1\ pounds avoirdupois). The um- 
bilicus was at one time believed to mark, at the full term, the middle 
point of the body, but the careful observations of Moreau and Olivier 
d'Angers show that this is not the case, but that the middle point is 
generally about three-fourths of an inch above the umbilicus. With 
the complete development of the child, there is, of course, increased 
thickness of the nails, and a considerable addition to the adipose tissue, 
which sometimes, indeed, is so considerable in quantity, as to raise the 
weight of the infant considerably above what has been set down as the 
average, and that without any corresponding increase in its length. 

Many fables have been narrated as to children which have been born 
weighing 20 to 30 pounds, and being 3J to 4 feet long. Twelve pounds 
is looked upon as a very great and unusual weight for a child at birth, 
but there are in this country few practitioners of experience who have 
not seen one or more such cases. In 4000 cases in the Maternite 
Madame Lachapelle only found one child which weighed 13J pounds. 
Dr. Rigby says that Sir Richard Croft delivered a living child 15 
pounds in weight. Mr. Owens delivered a woman of a stillborn 
child 1 which weighed 17 pounds 12 ounces. Another case of a still- 
born child which was said to weigh 19 \ pounds is given by Cazeaux, 
but the weight was not taken by himself, and he seems to admit a 
doubt of it. Putting aside increased dimensions from disease, the 
above may be received as the extremes of authentic cases. It must be 
remembered, however, on the other hand, that many children, even at 
the full term, weigh much less than the average ; but it is a recognized 
fact that, if the child be mature, it rarely survives if it weighs less 
than 5 pounds at birth, although its chance is considerably greater, if 
a child of that weight be born prematurely. Female children weigh 
and measure less than males, and on this point it is said by Burns that 
12 males are as heavy as 13 females. An interesting observation has 
been made by Dr. Guy, that " the mean weight of the bodies of still- 
born children, exceeds the weight of such as have lived one day, by 
from about \ to somewhat less than J-." In the last months, the size 
of the placenta becomes greatly reduced in proportion to the develop- 
ment of the child; thus, at the sixth month, it is nearly half the weight 
of the child, while at the full term it is but a sixth or a seventh. 

There are few matters of higher importance, with reference to the 

1 Lancet, 1835. 



128 



DEVELOPMENT OF THE EMBRYO AND FGETUS. [CHAP. 



relation which the foetus bears to enveloping and contiguous structures, 
than precision of nomenclature. At the same time, all who have had 
experience of the matter will confess that such precision, in regard to 
words which, in their vulgar acceptation, have a more extended signifi- 
cation, is a matter of no little difficulty. To obviate, as far as possible, 
any confusion which may arise, we shall here attach to the three words 
"attitude," "presentation," and "position," a definite meaning to which 
we shall adhere in the sequel as closely as possible; and it may further 
be remarked that a clear understanding on this subject has saved 
German authors from many of the errors and perplexities into which 
English writers have fallen. By the attitude or posture of the foetus in 
utero (Haltung) is meant the relation which its head, trunk, and limbs 
bear to each other; by presentation (Lage) is implied the relation of 
the long axis of the child to that of the uterus ; while the word position, 
in its strict and limited obstetrical sense (Stellung), indicates the relation 
which definite parts of the foetus bear to the anterior, posterior, or lateral 
regions of the abdominal or pelvic cavities. The varieties of a given 
presentation, according to the relation which the lowest or presenting 
part of the child bears to the pelvic canal, constitute the most familiar 
use of the last-named term. 

Presentation and Attitude of the Child in the Womb. — The shape of 
the womb being during the whole course of pregnancy more or less 
oval, the foetus is found to assume from the earliest period a correspond- 
ing presentation and attitude. In the early months of pregnancy, while 
the embryo still floats freely in the liquor amnii, and the envelopes of 
the ovum have not as yet come into contact with the uterine walls, the 
coincidence of the embryonic with the uterine ovoid is not an essential 

condition ; but, even thus early, the 
FlG - 72 - ovoid form is being assumed, as is shown 

by the bending forwards, which ap- 
proximates the cephalic to the caudal 
extremity. In this attitude, the devel- 
opment of the trunk and extremities 
proceeds, and, even at a period when 
there is still room for the foetus to 
stretch itself, and extend its limbs, we 
find it constantly with back and neck 
bent, and limbs drawn up and flexed. 
This attitude of the foetus becomes more 
marked as pregnancy advances; and, 
ultimately, at the full term, it is very 
constantly to be observed, as is shown 
in the accompanying diagram, with the 
vertebral column bent forwards, the chin 
inclined upon the sternum, the thighs 
strongly bent upwards on the belly, the 
knees bent, and the dorsum of the foot 
Attitude of the foetus in utero. inclined towards the shin-bone. The 

arms, more or less apart, are bent at the 
elbows, and the forearms are crossed or folded on the breast. In such 




VII.] CAUSES OF CEPHALIC PRESENTATION. 129 

a posture the child best adapts itself to the shape of the cavity in which 
it is inclosed, and which it pretty nearly fills. 

In no fewer than 96 per cent, of the cases of children born at the 
full term, the head of the child is turned — as in the figure — downwards 
towards the cervix of the uterus. The investigation of the causes 
which give rise to this law in gestation has long attracted the attention 
of obstetric writers. But, much as has been written on the subject, and 
ingenious as are many of the theories which have been advanced, it 
must be confessed that the problem has not yet been clearly solved. 
Few have prominently noticed the fact above mentioned, that the ovoid 
form of the foetus is assumed while it is yet the embryo, and before it 
has been subjected to any influence arising from contact with the uter- 
ine walls. Manifestly, however, there is a cause, — subsidiary it may 
be, — which acts thus early on the embryo, to insure its safety at a 
later stage. But the point which, to the exclusion of others, has at- 
tracted, in this matter, the greatest amount of attention, is the pre- 
sentation of the child, and the causes which lead to the inferior situation 
of the head in such an enormous preponderance of cases. 

The earlier theories which were propounded are more curious than 
instructive. It was very commonly assumed by the older writers that, 
in the early months, the head was normally uppermost, and that the 
sickness of early pregnancy w r as caused by an irritation of the diaphragm, 
produced by the hair on the scalp. It was, further, believed that about 
the seventh month the presentation became inverted, and that now, for 
the first time, the head was normally beneath. 

Of all the theories which have been advanced to account for the 
presentation of the head, none attracted so much attention, or gained 
so much credence, as that which led to the opinion that it was due 
simply to physical gravitation. The foetus, it was said, being suspended 
by its centre, in the liquor amnii, by means of the umbilical cord, its 
heavier, or cephalic, extremity must, of necessity, gravitate downwards; 
and this view was strengthened by the fact, that the point of suspen- 
sion was not the centre, but actually nearer the caudal extremity. It 
was obvious to those who refused to accept of this theory, that however 
it might be held as applicable to the first weeks of pregnancy, such 
a mechanism could have no share in producing or maintaining the 
presentation, after the cord had attained a length equal to the diameter 
of the ovum; and, further, if the theory were correct, that gravitation 
would be more likely to induce cephalic presentation in the early weeks 
of labor than at any other time. Every one knows, they argued, that 
on the contrary, it is not at the beginning, but at the end, of pregnancy 
that this is most constantly observed, and, therefore, the idea in ques- 
tion is wrong. Dubois, who took a prominent position in opposing 
the gravitation theory, further disproved it by some interesting experi- 
ments, which he made by plunging foetuses in water, and suspending 
them by the umbilical cord, when he found that it was not the head, 
but the scapula, or back, which hung downwards, and first touched the 
bottom of the vessel. And to these arguments it might be added, that 
the placenta is not always attached to the fundus — which situation could 
alone admit of such gravitation; and again, that, in the lower animals, 

9 



130 DEVELOPMENT OF THE EMBRYO AND FOZTUS. [CHAP. 

the theory of gravitation would place the head at the fundus, whereas, 
here also, we find the head turned to the os. In women, moreover, 
who maintain the horizontal position during the whole course of preg- 
nancy, the cranial presentation is as constant as in other cases. 

An ingenious plea in favor of gravitation, as a cause of the ordinary 
presentation, has more recently been advanced by Dr. Matthews Dun- 
can, who energetically controverts the opinions of Dubois, Simpson, 
and Scanzoni, and who insists, with much propriety, that, in deciding 
this point, we should always remember that, while the mother is in the 
erect posture, or when she is lying on her back, the uterus is far from 
vertical ; that, on the contrary, it is only when the trunk is inclined to 
the horizon, at an angle of 30°, that the uterus can be said to be ver- 
tical ; and that the mature foetus is only horizontal when the woman 
lies upon her side. Dr. Duncan's arguments are of too controversial 
a character to be usefully epitomized ; but they must be referred to with 
the respect which they merit, and which they will always command. 

The name of Dubois is, in this particular matter, associated with a 
theory, the evidence in favor of which is, we must admit, singularly 
inconclusive. M. Dubois supposed that, in obedience to some instinc- 
tive impulse, or act of volition, certain movements were, towards the 
end of pregnancy, executed by the foetus, with the object of bringing 
the head into the lower segment of the uterus. This renowned obstet- 
rician derives his chief argument from the harmony which he believed 
to exist between the object which nature had in view, and the means 
which she adopts, with a view to secure it. It is more than likely that 
Dr. Tyler Smith is correct when he surmises that, " had he (Dubois) 
written after the reception of Dr. Marshall Hall's great discovery of 
the spinal or physical movements, as distinct from the cerebral or 
psychical motor actions of the animal economy, he would probably 
have referred the motor powers of the foetus to reflex action, instead of 
to instinct or volition." 

The late Sir James Y. Simpson, in a series of admirable papers on 
this subject, has attempted to prove that the presentation of the foetus is 
due, in the first instance, to a succession of reflex or " adaptive" move- 
ments, and that, when it has once assumed the usual presentation, it is 
maintained in it, when displacement is threatened, by a repetition of 
similar reflex acts, which rarely fail to insure its reposition. It is in 
this way, and on this principle, that violent foetal movements succeed 
such changes in the maternal posture as may lead to the displacement 
of the foetus ; and he adds, further, that in cases of long cord, and in 
those in which the quantity of liquor amnii is much above the average, 
such movements on the part of the foetus are more frequent, and are of 
greater violence than usual. These last statements are certainly open 
to doubt. Cazeaux attaches great weight to the form of the uterus, as 
mechanically inducing the presentation of the foetus in the last months 
of pregnancy, the broader or breech end of the foetal ovoid being nec- 
essarily turned towards the fundus, and the smaller, or cephalic end 
consequently directed to the os. Some consider the child as composed 
of two ovals, one formed by the head, and the other by the trunk and 
limbs, and that corresponding to these, the outline of the uterus is 



VII.] 



CAUSES OF CEPHALIC PRESENTATION. 



131 



observed to consist of a portion of two ovals, as may be seen by look- 
ing again at Fig. 72. 

It mast be remembered, however, with reference to these various 
theories, that it is only in cases at the full term that the head presents 
in 96 per cent. ; and, with regard to most of the observations which 
have been made, that they have reference mainly to cases occurring at 
this period. It is universally admitted, that the earlier the period of 
the pregnancy, the less constant is the presentation of the child. The 
following table, founded upon the observations collected by Professor 



Period of Pregnancy. 


Total 
Cases. 


Presentations of 


Percentage of 

Head 
Presentations. 


Shoulder. 


Breech. 


Head. 


Before end of sixth month, . . . 
During seventh month, .... 
During eighth and ninth month, . 
At full term of gestation, . . . 


121 

119 

96 

100 


5 
6 
2 
1 


52 

31 

22 

3 


65 
82 

72 
96 


52 in 100 
68 in 100 
76 in 100 
96 in 100 



Dubois, at the Maternity Hospital of Paris, has been constructed by 
Simpson, and is, as he says, sufficient to prove "that the position (pre 
sentation?) of the foetus, with the head lowest, and over the os uteri, 
does not begin to be assumed till about the end of the sixth month, 
and that it is taken up with increasing frequency and certainty fro or 
that period onwards, to the full term of pregnancy." It must be no- 
ticed, however, with reference to this table, that, whereas the returns 
for the first, second, and fourth lines, have reference to children born 
during the specified period, whether alive or dead, the figures in the 



third line, of children born during 
the eighth and ninth month, refer 



Fig. 73. 



only to children born dead. 

The reason of the greater variety 
of presentation in the early months 
is sufficiently obvious. Not only is 
the child at this period smaller rel- 
atively to the cavity which is pre- 
pared for it, but the form of the 
cavity itself is such, as compara- 
tively to encourage changes of the 
presentation. Until the sixth month, 
the cavity of the cervix not ha vino; 
been as yet encroached upon, in the 
process of development, the child 
is contained in the cavity proper of 
the uterus, or rather of the body of 
the uterus. Most anatomists agree 
that, up to this period, the cavity is 
round, and not oval, so that, as in 

the annexed diagram (Fig. 73) a foetus of five months may move much 
more freely in any direction than is possible at the full time, when it 
is closely embraced by the pyriform or ovoid womb. 




Uterine cavity at the fifth month. 



132 DEVELOPMENT OF THE EMBRYO AND F03TUS. [CHAP. 

It must be confessed, however, that the causes which lead to the pre- 
sentation of the head constitute a subject still shrouded in no little ob- 
scurity. The fact being clearly established, we see no need to pin our 
faith exclusively upon a single theory, particularly as it is more than 
probable that most, if not all of them, point to individual causes which, 
acting successively, or in concert, produce the effect which we have been 
considering. No theory quite satisfactorily accounts for the fact that the 
embryo assumes its ovoid form at so early a date of development. We 
know, of course, what Harvey first taught, that " all animals, while they 
are at rest or asleep, fold up their limbs in such a way as to form an oval 
or globular figure.' 7 This has been ascribed by modern physiologists 
to the greater muscular tone and contraction of the flexor as compared 
with the extensor muscles; but, dating from a period of development 
antecedent to the formation of muscles properly so called, it is question- 
able whether even this will throw much light upon the point in question. 
In regard to the theory of gravitation, as originally promulgated, it is 
now sufficiently obvious that suspension by the cord cannot be the 
cause of the usual presentation at the end of pregnancy. It would be 
too much, however, to assume that gravity exercises no influence upon 
the foetus; indeed, the experiments of Matthews Duncan and Cazeaux 
point to a directly opposite conclusion. On the whole, however, we 
incline to the idea of reflex action, as affording the most reasonable 
theory which has yet been promulgated; but, far from shutting out the 
hypothesis of gravitation, we can conceive nothing more likely than 
that the vital force and the physical law act harmoniously together here, 
as elsewhere, at the bidding of nature. 

When the foetus is abnormally situated in the womb, the walls of 
this organ yield, and adapt themselves to the altered circumstances of 
the case. The bent posture is, however, always maintained, and the 
foetal ovoid is only distorted, in a marked degree, when the violent 
pressure of the contracting walls acts upon a misplaced foetus. It is in 
the ordinary presentation that the ovoid is most regular and marked, 
the larger pole being upwards, and occupying the expanded fundus, 
while the smaller is turned towards the vagina. If we take the 
longest, or bipolar measurement of the ovoid, at twelve inches, the 
broadest part of the larger end, from the lumbar region to the sole or 
edge of the foot, will usually be found to be about eight inches, and to 
correspond to the greatest transverse measurement of the cavity. Ob- 
viously, therefore, any marked alteration in the attitude or presentation 
of the child implies distorton of the outline of the womb. The fact of 
the smaller or cephalic end being only some four and a half inches in 
its larger or occipitofrontal measurement, has led to the idea which 
has been frequently expressed, w T ith reference to the mechanism of de- 
livery, that the child thus placed was a wedge, and that the smaller 
end dilated the parts for the passage of the larger breech. Nothing 
can, in point of fact, be more erroneous than this, or more likely to 
lead to serious practical blunders. For we find that, when the large 
end presents at the os, labor, far from being retarded, often advances, 
up to a certain stage, with unusual ease and rapidity, a fact which is 
owing to the plastic nature of the structures of which it is composed. 



VII.] THE FCETAL CRANIUM. 133 

If it were, in any sense, a wedge, the head, or apex of the wedge, would 
never fail to follow the breech at once, and with ease. But as it does 
not, and is often extracted only after much suffering, and at great risk 
to the child, we cannot admit the simile to be a happy one. The fact 
is, that the smaller end of the ovoid is the really formidable structure 
in the act of parturition, from its comparatively unyielding nature, — 
due to the special means which are adopted for the protection of the 
important nervous centre, upon the integrity of which the life of the 
infant depends. When the head has passed in safety, it is rarely, in- 
deed, that there is any difficulty in the birth of the other parts. To 
the obstetrician, therefore, one of the most important practical points 
in the study of his art is the thorough comprehension of the foetal 
cranium, and more especially of its relation to the pelvis, and to the 
other maternal structures which have already been described. 

The Foetal Cranium. — The bones which compose the cranium and 
face are found, at the period of delivery, to have reached different stages 
of development. With a view, no doubt, to the perfect protection of 
the important organs at the base of the brain,* the bones which form 
the base of the cranium, and the greater part of the face, are already 
so fused together as to admit of little or no movement. It is different, 
however, with the flat bones of the vault. The subjacent parts of the 
great nervous centre, being less essential to life, admit, with perfect 
impunity, of a certain amount of compression ; and, in order that full 
mechanical advantage may be taken of this circumstance, the ossification 
of the flat bones is comparatively imperfect. The various parts of 
which the cranium is composed are, of course, familiar to every student 
of anatomy. It will suffice, therefore, to notice those points only which 
are of special obstetrical interest. 

The Sutures are, first, the sagittal, which runs along the vertex, from 
the anterior to the posterior fontanelle. In continuation of this, there 
runs forwards a suture, which is peculiar to early life, and which is de- 
scribed by some writers as a part of the sagittal suture. This, which 
divides the frontal bone into two equal parts, is usually named the 
frontal suture. The coronal suture marks the line of demarcation be- 
tween the frontal and parietal bones ; while the lambdoidal suture runs 
outwards and dowmvards, from the posterior fontanelle, separating the 
posterior margin of the parietal from the occipital bone, and having 
thus the appearance of a bifurcation of the sagittal suture posteriorly, 
it presents some resemblance to the Greek letter from which it takes 
its name. At the base of each parietal is the suture which unites it to 
the corresponding temporal bone. 

The ossification of the bones, at all these points of contact, is so in- 
complete, as to admit of very considerable motion ; and in some situa- 
tions, — as at the sagittal suture, — the bones overlap each other to such 
an extent that, by reducing certain diameters, a great mechanical 
advantage accrues in the act of parturition. The angles of the bones 
are the points at which the development is least advanced, and it is 
here that certain gaps are left, where membrane only intervenes be- 
tween the scalp and the brain, and through which the pulsations of the 
latter may be observed. These gaps are called the Fontanelles. The 



13-i 



DEVELOPMENT OF THE EMBRYO AND FCETUS. [CHAP. 



largest, the great or anterior fontanelle, or bregma (Fig. 74, a), is 
irregularly lozenge-shaped, of considerable size, and easily recognized 
by the finger during labor. The larger portion of it is in front of the 
coronal suture, whence it is sometimes continued forwards, almost to 
the root of the nose. The posterior fontanelle (p) is very much smaller, 
and is triangular in shape. As the occiput is almost always turned 
forwards, it is this fontanelle which the finger usually touches in an 
examination during labor; but in well-developed crania, and more 
especially where overlapping of the sutures has taken place, it scarcely 
merits the name of a fontanelle, but is rather a point at which the 
lambdoidal and sagittal sutures meet. In a digital examination, it is 
of importance that the accoucheur should be able at once to distinguish 
between these fontanel les, for it is mainly by marking their situation 
that he is enabled to recognize the exact position of the head. At first, 
the student will find some difficulty in ascertaining this, but a little care 
and attention will soon enable him to overcome the trifling difficulty ; 
and he will find it useful, when in doubt, to run his finger round the 
gap, and count the sutures which run into it : in the case of the ante- 
rior fontanelle, these are four in number, and, in that of the posterior, 
three only. The tumefaction of the scalp, which is so common an oc- 
currence in difficult labor, may render such an examination difficult; 
but in the absence of this, the only circumstance which might mislead 
him, on a hurried examination, would be the presence of the irregular 
bones, called ossa triquetra. Some writers describe lateral fontanelles 
at the inferior angles of the parietal bones, anteriorly and posteriorly ; 
but these are so covered in by the temporal muscles, that it is only 
under very exceptional circumstances that their observation can be of 
any practical moment. 

It must now be obvious that a correct knowledge of the size of the 
cranium, and the relation which it bears to the pelvis in its various 



Fig. 74. 





Upper surface of foetal cranium. 



Diameters of the foetal cranium. 



diameters, must in no small measure be our guide to intelligent and 
skilful practice. Numerous measurements have been taken of the 
foetal cranium, for the most part between points arbitrarily selected. 
It is, however, only the most important of these diameters with which 



VII.] MEASUREMENTS OF FCETAL CRANIUM. 135 

the memory need be charged, viz., the occipito-frontal, the occipito- 
mental, and the biparietal; and, in addition to these, we shall mention 
only the trachelo-bi^egmatic and the fronto-mental. 

The Occipito-frontal, or long diameter of the oval cranium, is an 
imaginary line, extending from the frontal eminences anteriorly to the 
occiput posteriorly. It is somewhat doubtful what some authors mean 
in this case by " the occiput/ 7 but there is no doubt that most modern 
writers, who are exact in the matter, describe it as terminating at the 
summit of the occiput, or, in other words, at the posterior fontanelle. 
If, during labor, the attitude of the head in relation to the trunk were 
the same as in an adult in the erect posture, this would doubtless be 
correct. But if we recall the fact, that the chin of the child is applied 
to the sternum, and that the occiput passes into the pelvis considerably 
in advance of the forehead, it seems more correct to adopt the view of 
Cazeaux and some others, and draw our line (Fig. 75, a b) to the 
occipital protuberance. The actual measurement, it is true, is only 
fractionally greater, but the line indicated is certainly more nearly in 
coincidence with the plane of the pelvic brim and the upper part of the 
cavity, than that which is usually described. 

The Occipito-mental is the largest of the cranial diameters, and 
exceeds that just described, if we make an allowance for an average 
amount of moulding, by about an inch. It is thus of great importance 
with reference to the mechanism of parturition, and is represented in 
the figure by the line o m, drawn from the point of the chin to the 
posterior fontanelle. The Biparietal diameter (b b, 74) extends #ans- 
versely from one parietal protuberance to the other. The Trachelo- 
bregmatic, t t, is from the posterior extremity of the anterior fontanelle 
to the anterior margin of the foramen magnum ; and the Fronto-mental, 
b m, from the level of the frontal eminences to the point of the chin. 
Most of these diameters will be increased or diminished in direct pro- 
portion to the amount of pressure to which the head is subjected, and 
the consequent degree of moulding which it undergoes. It is, on that 
account, extremely difficult to state averages. But, besides, the recog- 
nized differences which subsist between male and female crania, not to 
speak of the varieties depending on race, still further increase the diffi- 
culty. Taking, however, the average of male and female crania in 
Europe, the following measurements probably come very near the 
truth, — if at the same time we make due allowance for average mould- 
ing, which, if we are to estimate the size of crania at the moment of 
birth, must certainly be done. 

Average Measurement of Male and Female Crania. 

Occipito-frontal diameter, ........ 4§ inches. 

Occipito-mental " ....... C>£ " 

Biparietal " 3 J " 

Trachelo-bregmatic " ....... 3^ " 

Fronto-mental " . . . . . . . 3£ " 

It is scarcely necessary to add, that these measurements refer to cases 
in which the head is born in the occipitoanterior position. In other 
cases of abnormal or unusual position, the moulding will be modified 



136 DEVELOPMENT OF THE EMBRYO AND F03TUS. [CHAP. 

to suit the requirements of the case, and the diameters will thereby be 
relatively altered. The same remark applies to circumferential measure- 
ments, which are usually stated, as regards the occipito-frontal circum- 
ference, as about fourteen inches, and for the occipito-mental as sixteen 
inches. According to Dr. Tyler Smith, "the ordinary presenting cir- 
cumference, which passes under the occiput, and round the parietal 
bones to a little behind the bregma, is about eleven and a half inches." 

In descriptions of foetal crania, and of cranial positions, the term 
"vertex" is constantly adopted by English and American writers. 
Unfortunately, however, this is one of several terms which are so 
loosely used, that it is necessary to give a definition before venturing 
to employ them. It is described in. Todd's Cyclopedia as synonymous 
with the anterior fontanelle; by Dr. Ramsbotham, as a point a little 
in front of the posterior fontanelle ; by Smellie, as the whole space 
between the two; and by Schmidt, as a point midway between the 
anterior and posterior fontanelle. Of all these, the most usual de- 
scription is that which places the vertex in or close to the posterior 
fontanelle. The expression " crown " or " vertex" implies that portion 
of the head which is highest in the erect posture. If so, the vertex 
can neither be the anterior nor posterior fontanelle, but a point inter- 
mediate between the two, varying somewhat according to the peculiar 
formation of different crania, so that it is difficult to determine the 
exact point. If it were absolutely necessary to describe it as such, we 
should probably closely approach the truth by placing it with Schmidt 
at a ^oint midway between the two fontanelles. But if we consider 
the infinite varieties which obtain in the relative situation of the two 
fontanelles, as regards the pelvic axes, so that any one point of the 
sagittal suture may in certain cases present, it then becomes obvious 
that to the term vertex we must attach a more extended signification, 
if we would avoid complicated systems of classification. On these 
grounds we prefer the definition of Smellie, and shall use the term 
vertex as including the sagittal suture in its whole length, and on either 
side that portion of the parietal bone (once called os verticis) which lies 
between the suture and the protuberance. 

Functions of the Foetus. — The Foetus being, during the whole period 
of its intra-uterine life, separated from the outer world, and immersed 
in a liquid medium, those functions which, after birth, are discharged 
under the usual atmospheric conditions, and in consonance with the 
ordinary laws of nutrition, fall to be performed after a fashion adapted 
to the peculiar circumstances of the case. We find, therefore, that, in 
the absence of aerial respiration, certain special modifications of the cir- 
culatory apparatus have been adopted, with the view of affording that 
gas to the blood, and that nutritive material to the frame, without 
which life within the womb would be a physical impossibility. A 
knowledge of this subject is essential both to the physiologist and to 
the accoucheur ; and it is only in the light of such knowledge that 
certain morbid phenomena and faults of development can be under- 
stood, and possibly, in some instances, obviated. 

The life of the foetus is maintained by an intimate union between the 
maternal and foetal circulatory systems, a union in which, although 



VII.] 



CIKCULATION IN THE FCETUS. 



137 



Fig. 76. 



there is no junction of the two currents, there is ample provision for 
the mutual interpenetration of gases and fluids, and also for the inter- 
change of cell elements. We do not allude now to the laws which regu- 
late the development of the early embryo, but to the union which sub- 
sists after the development of the organs of connection which have 
already been described, and which exist in almost all the Mammalia. 
The lungs of the foetus are, up to the moment of birth, apparently 
rudimentary. We say " apparently/' because, although in point of 
size and texture they present little resemblance to the organs of respi- 
ration, when that function has once been established, they are in the 
mature foetus already perfect in structure, and only await inflation to 
become the important organs, the function of which only ceases with 
life. In the adult, and dating from birth, the circulation is usually 
described as consisting of two tracts, mutually dependent upon, and 
yet in a sense distinct from, each other, the systemic and pulmonary 
channels, through which the whole column of blood continuously and 
successively flows. In the foetus, however, 
the function of the lungs being impossible, 
that portion of the circulatory current which 
is associated with the function of aerial res- 
piration is diverted from its course by special 
conduits, which join the circuit at a more 
advanced point, the pulmonary system being 
thus practically nil, although its apparatus 
is fully prepared against the moment of 
birth. From the systemic vessels, again, 
blood passes to the placenta by the umbilical 
arteries, and returns by the umbilical vein 
to join the general venous system of the 
child. As the other functions of the foetus 
depend chiefly upon the modifications of 
what we know as the adult apparatus, we 
may here describe these shortly. 

The Foetal Circulation. — The blood which 
returns from the placenta by the umbilical 
vein (Fig. 76, d) is charged with oxygen 
derived from the mother, so that the term 
"venous blood " is here, in its ordinary 
sense, inapplicable. After passing through 
the umbilicus, the vessel divides. A por- 
tion of its contents enters the liver, along 
with the blood which is being returned 
from the intestines by the vena portse (g), 
and, after circulating in that organ, enters 
the vena cava at h. The greater portion of 
it, however, passes direct to the vena cava, 
by the ductus venosus (a), which joins the 
main trunk at a point a little lower than the hepatic vein. The blood, 
being thus mixed with the systemic venous current, arrives at the heart 
much more feebly oxygenated than it was at the umbilicus, and passing 




Circulatory apparatus in the foetus. 



138 DEVELOPMENT OF THE EMBRYO AND FCETUS. [CHAP. 

into the right auricle, is directed by the Eustachian valve towards the 
foramen ovale, a special aperture through which the blood from the 
inferior cava is transmitted to the left auricle. From this point the 
current passes to the left ventricle, and from thence, as in the adult, to 
the aorta, almost the whole of this supply proceeding to the head and 
superior extremities by the three great vessels of the aortic arch, to 
return again to the right auricle by the superior cava. Although a 
mixture of the two currents from the vena? cava? must, to some extent, 
inevitably occur, the blood of the superior vein passes, almost in its 
entirety, through the tricuspid valve into the right ventricle, and thence 
to the commencement of the pulmonary artery. The condition of the 
lungs not being such as to receive this large column of blood, another 
special structure, the ductus arteriosus (r) is interposed, through which 
the current is diverted, and conducted directly into the descending 
aorta. Along with a little blood from the left heart, this column passes 
downwards to the lower part of the body, most of it going to the placenta 
by the umbilical arteries, from whence, charged with oxygen, it again 
returns to the vena cava inferior. It will be observed that three 
special conduits thus exist; two of them, the foramen ovale and ductus 
arteriosus, being designed with the direct object of diverting the circu- 
lation from the lungs, while the other serves to connect the vena cava 
with the umbilical vein. In addition to these, which are completely 
obliterated after birth, there are the umbilical arteries, which are per- 
manent in a portion of their course, forming the internal iliac and 
superior vesical arteries. 

The Lungs enter upon their function immediately upon the birth of 
the child, and when anything occurs to prevent the speedy occurrence 
of the respiratory act, the child is stillborn. The sudden inflation of 
the lungs which thus occurs, and the arrest of the placental circulation, 
consequent upon the separation of that organ from the mother, give 
rise to immediate changes in the direction of the current, which are the 
first steps in the obliteration of the special foetal structures which have 
been described. The essential phenomenon is the transference of the 
seat of respiration from the placenta to the lungs. By the consequent 
development or unfolding of the pulmonary vessels, a vacuum is created, 
which draws the blood from the right ventricle directly, and for the 
first time, into the pulmonary circuit. The aorta, lacking thus the 
important source of supply which it had hitherto derived from the 
ductus arteriosus, sends a diminished supply of blood in a feeble stream 
to the umbilical arteries, thus encouraging the stasis of the blood in the 
foetal portion of the placenta. This causes a diminution, and soon a 
complete cessation, of the flow of blood outwards through the umbilical 
arteries, and of its return through the umbilical vein. When the left 
auricle is sufficiently supplied, by the return of the blood from the lungs 
through the pulmonary veins, the foramen ovale is closed by the pressure 
of the blood upon its valve, the closure being further encouraged by 
the diminution in the supply of blood to the right auricle, which is the 
necessary result of the arrested circulation in the umbilical vein. These 
facts make it clear how important it is for the mechanism of the circu- 
lation, that the establishment of aerial respiration should besimultane- 



VII.] RESPIRATION IN THE FCETUS. 139 

ous with the arrest of the placental circulation. It is only upon the 
complete establishment of the pulmonary circulation, that the distinc- 
tion between arterial and venous blood can, with perfect propriety, be 
drawn. There is no longer a mingling of the two currents, and they 
now assume within their proper vessels the physical characteristics which 
serve to distinguish them. 

The time at which the obliteration of the foetal apertures takes place, 
and the order in which they close, are facts of some medico-legal im- 
portance. Effective closure, if not obliteration, of all of them, will 
generally be found to have occurred by the ninth day, although they 
may remain patent for twelve or fifteen days, or even longer, without 
any inconvenience to the child. The umbilical arteries are usually 
impermeable from the second day, owing to contraction and thickening 
of their walls ; the umbilical vein and ductus venosus always close after 
the arteries, generally about the sixth or seventh day. The ductus 
arteriosus and foramen ovale are the last to be obliterated, but rarely 
remain permeable longer than the period above stated. In regard to 
the latter, it has been said that, while it is the last to close, it is the 
first to contract. In the embryo, there is but one auricular cavity; 
but, about the third month, a semilunar valve, containing fleshy fibres, 
marks the first growth of the partition which ultimately separates the 
right from the left auricle. Permanence of the aperture may constitute 
the affection known as Cyanosis. Dr. Tyler Smith is of opinion that 
the closure of the foetal apertures is, in a great measure, due to the 
mechanical effect of the inflation of the lungs; and there can be little 
doubt, we believe, that this contributes to the result, by the pressure 
which is exercised, in the one direction, by the left bronchus, upon the 
ductus arteriosus, and, in the other, by the displacement downwards 
of the liver, upon the umbilical vein and ductus venosus. The changed 
position of the heart also tends to the closure of the foramen ovale. 
Another very marked result of the alteration in the circulating system — 
one which acts somewhat more slowly — is the thickening of the walls, 
and augmentation in the capacity, of the left heart, which, prior to 
birth, is subordinate to the right heart in both of these particulars. In 
three or four weeks this change is very obvious. 

The blood of the mature foetus does not differ materially from that 
which occupies the vessels after birth ; but, owing, no doubt, to the 
comparatively imperfect arterialization which takes place in the pla- 
centa, and the manner in which the two systems mingle, there is not 
observed that contrast in color which enables us to distinguish arterial 
from venous blood. As regards the blood of early embryonic life, few 
opportunities occur in which it can be examined ; but, from what has 
been observed, it would appear that it is of a dark color, coagulates 
feebly, is deficient in fibrin, and becomes but little reddened on ex- 
posure to the atmosphere. 

Respiration. — From what has just been said, in reference to the 
course of the circulation of the blood in the foetus, it will be obvious 
that the respiratory function must be carried on in the placenta — the 
most important of whose functions, indeed, is that of an intra-uterine 
lung. We need not pause here to discuss exploded theories, as to the 



140 DEVELOPMENT OF THE EMBRYO AND FCETUS. [CHAP. 

source from which oxygen is derived by the foetus. The researches of 
Bisch off proved that, even in the embryo, respiration by means of the 
branchial fissures is impossible, and that, in point of fact, these struc- 
tures have no connection whatever with this function, as was at one 
time erroneously supposed by Geoffroy Saint-Hilaire and others. Two 
facts stand out prominently : first, that a constant supply of oxygen 
is necessary to the life of the foetus ; and, second, that that supply 
cannot be obtained directly from the air. Whence, then, is it derived ? 

The full description, which was given in a former chapter, of the 
structure of the placenta, may suffice for an answer to this question, in 
so far as regards that period of intra-uterine life during which the 
placenta exists. But, for the period of embryonic life, some further 
description is required; and, indeed, there is still, in regard to this 
point, some necessity for extended research. M. Serres has described 
two periods — the first of these, which he terms the period of branchial 
respiration, exists down to the time when the placenta is formed. He 
assumes that, among the villi of the chorion, there are a certain number 
(villosites branchiales) which dip into the lacunae of the decidua reflexa, 
and are there bathed in a special fluid, from which the supply of oxygen 
is derived until, in the course of development, the second, or placental 
period arrives. To what extent, if at all, this theory may be admitted 
as correct, it is at present impossible to determine; nor would it serve 
any good purpose to enter here upon the discussion of this, or any 
mere physiological speculation. We shall at once, therefore, assume, 
as facts hitherto observed entitle us, that from the earliest period at 
which the necessity of a respiratory function may arise, the essential 
supply of oxygen is derived from the mother, and passes through the 
external surface of the ovum, the villi of the chorion, or the villi of 
the placenta, according to the stage of actual development. The func- 
tion of respiration involves the interchange of gases; but whether this 
interchange takes place in consonance with the laws which regulate 
interpenetration of fluids, or by passing through some intermediate 
vehicle, as is presumed by Serres, the source of the supply may, in all 
cases, be assumed to be the same. In point of fact, the respiration of 
the foetus bears the strictest analogy to the branchial respiration of 
fishes, in which a membranous structure only is interposed between 
the blood and the liquid from which the oxygen is to be derived. In 
the placenta, as we have seen, the parts are so disposed as to bring as 
large a portion as possible of the two systems, maternal and foetal, into 
contact. 

That, in consequence of this contact, the blood undergoes important 
and vital changes is proved by many facts, pathological and otherwise. 
To compress the cord, is to cause the certain death of the foetus; but 
more significant even than this is the fact, that after death from this 
cause, the physiological phenomena of apnoea are invariably developed. 
There exists, also, a marked respiratory antagonism between the 
placenta and the lungs. So long as the placental circulation is still 
uninterrupted, the newborn infant may live without pulmonary respi- 
ration ; but, so soon as it breathes strongly, the blood no longer passes 
by the cord, or if it persists to a certain extent, it may at once be stopped 



VII.] NUTRITION OF THE FGETUS. 141 

by ligature. But if the child has not breathed, it is always wrong to 
tie a pulsating cord until aerial respiration has been set up. Finally, 
the respiratory function of the placenta has been proved by analysis of 
the blood from the umbilical arteries and veins, that in the vein always 
showing a comparative abundance of oxygen, although, as already 
mentioned, the quantity of the gas is not sufficient to establish that 
marked difference in color, which enables us so readily to distinguish 
between ordinary arterial and venous blood. 

Nutrition. — This function is intimately associated with that of res- 
piration. All modern physiologists admit that the nutritive supply 
comes from the mother, but the exact manner in which it is absorbed, 
and the proportion in which it passes through various channels and 
media are points which have given rise to endless disputes, and many 
hypotheses. It is certain that the nutritive material cannot, at all 
stages of embryonic and foetal development, pass through the same 
course in its way from mother to child ; and, in truth, our knowledge 
of the history of development prepares us for the admission that the 
plan of nutrition must differ materially according to the stage at which 
the fertilized ovum has arrived. Even at the very earliest stage, while 
it still moves freely in the Fallopian tube, absorption from maternal 
sources may take place by endosmose through its external envelopes, 
which also admit of penetration by the fertilizing sperm of the male. 
But, in addition to this, there is a store of material, which we have 
reason to believe is in a great measure nutritive, contained in the um- 
bilical vesicle. The quantity of this, and the proportion which it bears 
to the size of the embryo, is at first very great, but as changes succeed 
each other within the ovum, in the manner already described under the 
head of development, the relative quantity dwindles, and the reservoir 
itself becomes ultimately absorbed, after being drained of its contents. 
The connection of the umbilical vesicle with the rudimentary intestine, 
the chemical composition of its contents, and, more significant still, the 
establishment in its walls of bloodvessels proceeding from the foetus, 
suffice to prove this position. After the development of the allantois, 
vessels are carried from the embryo to the chorion : the villi of the 
latter become enlarged and vascular, implant themselves in the decidua, 
and thus bring foetal vessels and foetal blood into the closest contact 
with the mother. Some have even believed that the villi plunge into 
the utricular follicles, and thence derive their pabulum. 

With the formation of the placenta, this contact becomes localized, 
and at the same time, owing to the peculiar structure of that organ, is 
greatly increased in extent. Through the delicate membranes which 
separate the one system from the other, and in addition to the gaseous 
supply which constitutes the respiratory function of the placenta, there 
pass incessantly, in fluid form, materials which go to the building up 
of the foetal tissues. But it is not alone by a mere endosmose, or by 
mutual interpenetration, that this nutritive function is carried on, but 
by a process of intermediate cell-growth, in the course of which, 
materials are elaborated, with the express object of foetal nutrition. 
Goodsir's theory on this point is illustrated by the accompanying dia- 




142 DEVELOPMENT OF THE EMBRYO AND F03TUS. [CHAP. 

gram (Fig. 77). His observations led him to the conclusion that the 
blood, in the vessels of the mother, is separated from that in the ves- 
sels of the foetus, by the intervention of two distinct sets of nucleated 
cells. One of these, c, belongs to the maternal 
Fig. 77. portion of the placenta, lies in contact with, 

and external to the ultimate maternal vessels, 
and is probably designed for the separation 
from the blood of the mother of the materials 
destined for the foetus. The other layer,/, lies 
between the membrane of the foetal villus and 
the wall of the vascular loop which it contains, 
the object of these cells being to receive the 
Diagram illustrating Goodsir's material which has been elaborated on the other 
theory of foetai nutrition. s \ ( ] e ^ Between the two there is a space, d, into 
which the materials secreted by one set of cells 
is poured, in order that it may be absorbed by the other. In this way, 
it is probable that not only are materials passed from the mother to the 
foetus, but that, through the same agency, effete or excrementitious 
matters are transferred from the foetal to the maternal blood. 

Another source from which nutriment may be drawn is the liquor 
amnii. Substances introduced into the stomach or blood of the female 
have been found in this medium, as well as in the foetus and placenta, 
and its analysis has proved it to contain albumen, osmazome, and salts. 
Besides this, newly born calves have been kept alive by fresh amnionic 
fluid during a period of fifteen days. This being the case, many theo- 
ries have been advanced, with the view of proving that nutritive ma- 
terial passed by this channel from the mother to the foetus. The mam- 
mary glands, the genital organs, and the alimentary canal, have all 
been upheld as constituting the mediate channel of communication ; 
but there can be little doubt that such communication, if it occur at 
all, is most likely to take place through the entire cutaneous surface. 
This idea is confirmed in an especial manner by the observations of 
Brugmans, who found, on removing the embryo from the amnionic 
pouch in living animals, that the lymphatic vessels of the skin were in 
an engorged condition, while those of the intestines, the functions of 
which had yet to be established, were found to be empty. If we admit 
that these facts establish the belief of nutrition through the liquor 
amnii, we see no reason to doubt what Scanzoni asserts, that a similar 
absorption may take place through the Avails of the umbilical cord, and 
that this would be a more direct way than any to the main channel of 
the foetal circulation. Beyond all doubt, however, the main source of 
nutritive supply to the foetus is the placenta, while the liquor amnii 
may be looked upon as an auxiliary medium, through which, possibly, 
certain special elements may be admitted. 

Secretions. — The secretions of the foetus are similar in their nature to 
those which are found after independent existence has been established, 
but are, according to the period of development, in a more or less 
rudimentary condition. It is necessary to mention here three only, the 
Bile, the Urine, and the Meconium. 



VII.] FCETAL SECRETIONS. 143 

The Liver is, in proportion to the size of the foetus, and in com- 
parison with the same organ in adult life, a viscus of great size. Prior 
to the fifth month, its structure is soft and pulpy, and the gall-bladder 
has the appearance of a white cord ; but about this period the secretion 
of the bile commences, the characteristic structure of the liver becomes 
developed, and the gall-bladder begins to distend. Besides acting as 
an assimilating organ, by preparing materials for the blood and the 
tissues, its proper secerning function is to separate the hydrocarbona- 
ceous portion of the protein compounds, and this function it discharges 
in the foetus, with special and increasing energy, after the placenta has 
been fully formed, most physiologists being of opinion that it is by 
this channel, and not through the placenta, that the carbon and other 
effete materials are chiefly removed. At the end of the seventh month, 
the gall-bladder will usually be found distended with bile, and a con- 
siderable quantity of its contents, charged with carbon, makes its way 
into the intestine. 

The name meconium is that which has been given to the excremental 
materials which are contained in the alimentary canal of the foetus. 
Up to the third month, the inner surface of the canal presents a slight 
moisture, but about this period the stomach and duodenum contain a 
small quantity of whitish albuminous fluid. At the beginning of the 
sixth month the contents of the small intestine will be found to have 
assumed a deep yellow color, owing to the admixture of bile, which 
gradually becomes darker in hue as pregnancy advances. The meco- 
nium now enters the great intestine, and ultimately, about the end of 
the term, occupies the rectum in considerable quantity, from whence it 
is ejected in presentations of the breech, and under various other cir- 
cumstances which need not be here detailed. The meconium, then, is 
the result of a mixture of foetal bile with the material secreted by the 
mucous membrane of the digestive canal. 

The Urine is secreted at an early period of intra-uterine life, when 
the structure of the kidneys is already very considerably advanced. 
It was at one time supposed that the bladder communicated directly, 
by the urachus, with a cavity in the allantois, which thus constituted 
a reservoir for the urine. The allantois, however, in man at least, no 
longer exists as a cavity at the period when the kidneys form and the 
secretion of urine begins, so that we are forced to believe that the 
urine must be evacuated into the amnionic cavity, a fact which seems 
to have been established bv the discovery of urinary materials in the 
liquor ainnn. 



144 PREGNANCY. [CHAP, 



CHAPTER VIII. 

PREGNANCY : SIGNS OF PREGNANCY. 

PREGNANCY — THE GRAVID UTERUS: MUSCULAR FIBRES OF: MUSCULAR LAYERS — 
CHANGE IN FIBRES AFTER DELIVERY — DEVELOPMENT AND ANATOMICAL RELA- 
TIONS OF UTERUS AT VARIOUS STAGES OF PREGNANCY — SIGNS OF PREGNANCY: 
SUPPRESSION OF THE CATAMENIA — DIGESTIVE DISORDERS: MORNING SICKNESS : 
SALIVATION — KIESTEIN — CHANGES IN THE MAMMAE: PAIN: ENLARGEMENT: 
SECRETION OF MILK : AREOLA: CHANGES IN NIPPLE, AND IN GLANDULAR FOL- 
LICLES : SECONDARY AREOLA — ENLARGEMENT AND EXTERNAL APPEARANCE 
OF ABDOMEN : FLATTENING IN EARLY MONTHS: CHANGE IN THE APPEARANCE OF 
UMBILICUS : DIAGNOSIS OF OTHER ABDOMINAL TUMORS — VAGINAL EXAMINA- 
TION : COLOR: DIGITAL EXAMINATION : VAGINAL PULSE. 

While the ovum undergoes, in the progress of its development, the 
changes which have been detailed, the organism of the mother is also 
the seat of important anatomical changes and physiological phenomena. 
Among these, the changes which occur in the uterus naturally attract 
very considerable attention. 

The Gravid Uterus, when we compare it with the unimpregnated 
organ, presents alterations, not only in magnitude, but in structure. 
Nothing could be more erroneous than the idea of the old physiologists 
that its development was a mere distension, similar to what takes place 
when we inflate an india-rubber bottle. There is, on the contrary, an 
increase in the quantity of its tissue, whereby its weight is progressively 
increased up to the end of pregnancy ; and there is, moreover, an 
alteration in the tissues of which it is composed, raising its structure, 
so to speak, to a higher physiological level. The changes which the 
mucous membrane undergoes have already been incidentally referred 
to in connection with the formation of the decidua. In regard to the 
tissue proper of the uterus, we have found it, in the unimpregnated 
state, to be composed of interlacing fibres, which are somewhat irregu- 
larly disposed. Had no opportunity ever existed of examining them 
in a gravid womb, it would perhaps have been held a bold speculation 
to maintain that these fibres are muscular elements of the non-striated 
variety. In the present state of histological science, nothing is more 
clearly demonstrated than that this is the case, even if the expulsive 
contractions of the uterus had not pointed to a similar conclusion. 
This is indicated with great distinctness in the accompanying illustra- 
tion (Fig. 78), where a, a, are nucleated fibre-cells from the unimpreg- 
nated uterus. Their embryonic or undeveloped condition shows in 
marked contrast with cells from the gravid uterus, which are shown 
in 6, b, c, c, and c, at different stages of development. 

These fibres, which constitute so large a portion of the bulk of the 
womb, have, from the time of Vesalius, been described by anatomists 



VIII.] 



THE GRAVID UTERUS. 



145 



as forming layers; but the contradictory statements made on this sub- 
ject by the earlier anatomists serve to show FlG 78 
what may very easily be seen by examin- 
ing the uterus for ourselves, that the fibres 
are far from being regular and distinct in 
their course. This is more especially the 
case with regard to the unimpregnated 
uterus ; but when conception has occurred, 
and the fibres have reached the higher 
stage of development figured above, not 
only are the fibres themselves more dis- 
tinct, but their disposition in layers be- 
comes more apparent. It must be con- 
fessed, however, that not even the careful 
dissections of Hunter and Madame Boivin, 
nor the microscopic researches of Kolliker, 
have as yet clearly demonstrated what is 
the exact arrangement of these layers. It 
may be asserted, no doubt, in general 
terms, that the fibres are irregularly dis- 
posed in this, as in the other hollow viscera, 
so as to form an external or longitudinal, 
and an internal or circular group ; but 
when we come to look at the actual draw- 
ings upon which these statements are based, 
we cannot fail to be struck with the fact 
that, as regards the outer layer, a very 
small proportion only of the fibres can be 
truly described as longitudinal. The ac- 
companying cut (Fig. 79) shows the poste- 
rior surface of the uterus, from which the 
peritoneum has been carefully removed, 
so as to exhibit the external layer of the 
muscular tissue. It will be observed that 
the fibres appear to proceed from the sides 
of the uterus, where they are continuous 
with those which pass along the round 
ligament, the broad ligament, the ligament 
of the ovary and the Fallopian tube. Their 
direction therefore is, in the main, trans- 
verse, and when they reach the middle line 
some of them pass across, interlacing with 
their fellows of the other side; while a 
certain number, according to Cazeaux, turn 
upwards and downwards, after interlacing, 
to form the band of longitudinal fibres which 
is shown in the figure, and which is continu- 
ous with numerous powerful bundles pass- 
ing over the fundus. A somewhat similar „., „ , *. \ * * 

j. . . . ■, . n libre-cells of the unimpregnated and 

disposition is seen on the anterior surface. gra vid uterus contrasted. 

10 



146 PREGNANCY. [CHAP. 

The inner layer, as described by William Hunter, and before him, 
though much less accurately, by Ruysch, is that which corresponds to 
the circular layer of the other viscera. It is thin, and composed of 
groups of fibres, the general direction of which is transverse, but ar- 
ranged at either angle of the uterus, in a concentric manner, around 
the orifices of the Fallopian tubes, as shown in Fig. 80. Other groups 

Fig. 79. Fig. 80. 






External muscular layer of uterus. Internal muscular layer of uterus. 

encircle the middle of the body of the uterus, while others again are 
described as forming a sort of sphincter surrounding the os uteri. 
Between these two layers, a third or middle layer is generally described 
by modern anatomists, as being of considerable strength and thick- 
ness, with numerous bundles, flattened, and running in all directions 
in the substance of the or^an. These interlace freely, and surround 
the vessels of the uterus, so that, when the organ is in a state of con- 
traction, these vessels must be notably diminished in their calibre. 
Indeed, there is every reason to believe that it is mainly by their agency 
that haemorrhage is prevented after the separation of the placenta, the 
ruptured and gaping orifices of the utero-placental vessels being there- 
by closed. 

Inseparably connected with the subject which we are now consider- 
ing, is that of the involution of the uterus, or that process whereby the 
organ returns, after delivery, to a size and structure approaching that 
of the unimpregnated state. That the uterus, in a short time, is reduced 
in weight, from about twenty -four ounces to two, involves the certainty 
that rapid absorption takes place under very special conditions. How 
this takes place has been indicated by many physiologists, but by none 
has it been demonstraed so clearly as by Kolliker. The enormous fibre- 
cells which exist at the termination of pregnancy, are now huddled 
together in contraction, and, their function being over, absorption takes 
place, under favorable conditions, with great rapidity. They become 
the seat of rapid atrophy, and fatty degeneration, and the whole mass 
of the muscular tissue becomes soft and friable. The separation of 
individual fibres for microscopic examination is, on this account, not 
easy ; but if successfully removed, they will be found as represented in 
Fig. 81, where the appearance presented by them a fortnight after de- 



vin.] 



THE UTERUS DURING PREGNANCY. 



147 



livery is shown at a. About the fourth week, the development of new 
fibres in various stages b, may also be observed. A large portion of 
the fatty and disintegrated matter is removed by the vagina in the 
lochial discharge; and a proportion still larger is probably absorbed 
into the circulation, and discharged ultimately from the system by the 
ordinary excretory channels. The latter has been supposed to contrib- 
ute to the formation of the caseous matter in the milk first secreted. 

That portion of the peritoneum which invests the uterus and neigh- 
boring parts, is evidently so disposed in the unimpregnated state, as to 
admit of free extension during pregnancy. ' It is in this way that the 



Fig. 81. 



Fig. 82. 





Degeneration of fibre-cells after 
delivery. 



Diagram, showing development of uterine cavity. 
(After Schultze.) 



broad, as well as the anterior and posterior ligaments unfold themselves, 
as the uterus slowly develops, until, at last, they entirely disappear. 
But it is not by a mere mechanical process such as this, that the serous 
covering of the womb adapts itself to the exigencies of the pregnant 
state, but, in addition, by an actual hypertrophy of its tissue. Were 
the former alone the case, the extension thus furnished would not be 
possible without thinning of the membrane; but as we invariably find 
that, at the very end of pregnancy, the membrane in question is as 
thick as before, we infer, that in this case, as in large hernia? and cer- 
tain other morbid conditions, the serous, as well as the muscular and 
mucous coats of the womb, undergo marked hypertrophy. 

The development of the ovum within the womb, the various stages 
of which we have traced, is necessarily accompanied by a corresponding 
increase in the volume of the uterus, and by marked changes in its 
anatomical relations. In the shape of the organ there is, from the first 
weeks, a marked alteration in respect of the antero-posterior flattening ; 
and, as the pregnancy advances, the general form approaches more a 



148 PREGNANCY. [CHAP. 

spheroidal than a pear shape. From the twelfth to the twenty-fourth 
week, the cavity assumes more and more of a rounded appearance, but 
still retaining a certain amount of the antero-posterior flattening, and 
its length is also somewhat greater than its width ; but, speaking in 
general terms, the cavity of the uterus may, at the last-named period, 
be described, as it is shown in the diagram (Fig. 82), as circular. Dur- 
ing the remaining sixteen weeks of gestation, the rounded shape of the 
uterine cavity becomes changed into an oval, so that at the end of preg- 
nancy the womb is about twelve inches long, nine broad, and eight 
I from before backwards. This change is brought about, as has gener- 
ally been believed, by an invasion of the canal of the cervix, which 
takes place now for the first time, and which acts from above down- 
wards. The numbers 30, 36, and 40, are supposed to represent, by 
the dotted lines, the extent to which, at these weeks, the uterine cavity 
has increased at the expense of the cervix. The crosses mark upon 
the uterine wall the site of the original os internum. To this subject, 
and more particularly to the state of the os and cervix as a sign of preg- 
nancy, we shall revert. 

These alterations in the form of the uterus, must needs be accom- 
panied by changes, no less marked, in its situation and anatomical rela- 
tions. During the first twelve weeks of gestation, the womb remains 
within the true pelvis, or cannot, at least, be felt above the pubes ; 
although, on pressing the fingers somewhat deeply, it may be readily 
discovered. Seeing that the fundus is originally very near the level of 
the brim, it follows that the considerable increase in bulk which these 
weeks bring must find room in another direction. We find, therefore, 
that the development, under the circumstances, goes on in a downward 
direction, and that the os and cervix are discovered, on examination, 
to be much nearer the floor of the pelvis than they were before impreg- 
nation. It thus obeys, so far, the laws of gravity, and the weight of 
the intestines resting upon the fundus may, in some measure, contribute 
to the result. The progress of foetal growth soon renders it impossible 
for the uterus and its contents to remain longer within the pelvis; and 
if under peculiar circumstances, it be so, the safety, both of mother and 
child, is immediately endangered. The presence of the rectum on the 
left side is assumed by many to be the cause of a change in the ana- 
tomical relations of the uterus, which very generally takes place, and 
which consists in a deviation of the fundus to the right side. In the 
course of the fourth month, the fundus can usually be felt by the fin- 
ger of the accoucheur, above the pubes. The level which it attains 
at various periods of pregnancy depends upon the condition of the ab- 
dominal walls, and upon many other circumstances which render exact 
statements upon this subject impossible. Very generally, it will be 
found to have attained the level of the umbilicus some time in the 
course of the sixth month. About the thirty-sixth or thirty -seventh 
week, it reaches the level of the xiphoid cartilage ; but between this 
time and the end of pregnancy, it falls downwards and forwards, pre- 
paratory to the phenomena of parturition. 

In rising from the pelvis, and going through the succeeding stages 
of its development, it is easy to understand how the uterus, with a ten- 



VIII.] EARLY SIGNS OF PREGNANCY. 149 

dency towards the right side, will be still more encouraged in its move- 
ment in that direction, by the prominence of the vertebral column in 
the middle line. Or, if we reject the theory of the influence exercised 
by the rectum, we still see, in the relations which subsist between the 
expanding uterus and the vertebra?, a sufficient cause for deviation 
from the middle line. And it is certain that, in a large proportion of 
cases, this deviation is to the right side. 1 If we reflect that the line 
which represents the axis of the uterus, is nearly coincident with the 
axis of the brim of the pelvis, and remember the marked projection 
of the lumbar vertebra?, we shall have no difficulty in appreciating the 
causes which lead to the uterus being in immediate contact with the 
anterior abdominal wall, so that it is a rare occurrence when we find 
any portion of the intestines intervening between the abdominal and 
uterine walls in this situation. At the termination of pregnancy, then, 
the uterus, with the ovaries, Fallopian tubes, and other structures 
closely applied to its sides, occupies a great part of the abdominal cav- 
ity. Its usual relations are as follows : in front with the vagina, the 
neck and posterior wall of the bladder, and the anterior abdominal 
wall ; behind, with the rectum and the promontory of the sacrum 
below, and the mesentery and the intestines above ; on the right, by 
the caecum and the right abdominal wall ; and, on the left, by the 
sigmoid flexure of the colon, and, usually, the great bulk of the small 
intestines. 

Signs of Pregnancy. — The development of the womb, and that, al- 
ready described, of the germ which it contains, constitute the essential 
anatomical and physiological phenomena of the pregnant state. Asso- 
ciated with it, however, and dependent upon its continuance, are nu- 
merous other manifestations, which have their seat in organs so remote, 
that it is difficult, in many cases, to trace the sympathy which exists 
between them and the special organs of generation. There is, in point 
of fact, no single function of the whole economy which may not be 
affected by the operation of a cause which has its centre in the genera- 
tive organs, and which radiates thence throughout the entire system. 
Consequently, phenomena are frequently observed in distant organs, 
which are certainly not associated in function with the womb ; but so 
constant is the occurrence of these phenomena, that they have come to 
be familiarly looked upon as among the early symptoms of pregnancy. 
More important are the symptoms which have their cause and seat in 
the generative organs ; but in the observation even of these, there are, 
as in the case of the others, so many sources of fallacy, so many pit- 
falls of error, that obstetrical writers have uniformly, and with obvious 
propriety, made a study of the signs of pregnancy, — one of the most 
prominent objects to which it is desirable that the attention of the 
student in this department should be drawn. We can conceive no 

1 It has been held, among the causes which have been advanced to account for 
this displacement to the right, that the weight of the placenta gave rise to it, — it 
being more frequently, according to Levret, on the right side. The presence of the 
descending colon on the left, the habitual use of the right hand in preference to the 
left, and the habit of lying on the right side during sleep, are a few among the many 
reasons which have been propounded to account for the phenomenon. 



150 SIGNS OF PREGNANCY. [dlAP. 

subject in regard to which a mistake might so utterly ruin a young 
man's hopes, than the determination, in delicate or doubtful cases, of 
this question of pregnancy. An obvious pregnancy overlooked, be- 
cause the idea has never crossed the mind, is bad enough ; and we have 
known a practitioner of thirty years' standing blister the abdomen in 
the ninth month, under the idea that he was treating a morbid growth. 
But what is far more inexcusable, is the culpable rashness of those 
w r ho, without irrefragable evidence of the existence of pregnancy, 
would venture — as has been done in high quarters — to brand a woman 
with the stigma of dishonor. To enable the practitioner to avoid these, 
and similar errors, the symptoms which indicate pregnancy have been 
arranged, with a view, more especially, of assigning to each its actual 
diagnostic value, and determining the period at which, in the course of 
a pregnancy, it is available. We shall find that the number of symp- 
toms which are of themselves conclusive as evidence of pregnancy is 
very limited; but the other, and more numerous group, constitute an 
important chain of circumstantial or corroborative links, which, under 
ordinary circumstances, enable us to admit the strongest probability of 
an event which may be either dreaded or longed for. The convictions 
of a woman whose most earnest desire is to be a mother, and the pas- 
sionate asseveratious of another whose chastity is called in question, 
are disturbing elements which tend to throw us out in our calculations, 
and must always be taken cum grano. 

In classifying the signs of pregnancy, various plans have been 
adopted, but what seems more rational, and what certainly is much 
more satisfactory than any attempt at rigid classification, is to take up 
the symptoms, as nearly as may be, in the order in which they are 
manifested. The earliest of all the symptoms have their seat in the 
generative organs, but are of little value from a practical point of view, 
inasmuch as they consist in physiological and anatomical manifestations 
which are almost entirely beyond our ken. It is certain that the fer- 
tilized ovum, on its arrival within the cavity of the uterus, finds that 
organ in a condition suitable for its reception. Probably the condi- 
tions which we have seen to exist, in ordinary healthy menstruation, 
as regards the tissues of the womb, are, under the special circumstances 
of conception, prolonged, and ultimately pass, by a series of develop- 
mental changes, some of which have been described, into those which 
are characteristic of the more advanced stages of pregnancy. Or, sup- 
posing even the uterus to be quiescent, and not under the influence 
either of a past or of an impending menstrual molimem, we may as- 
sume that one of the earliest effects of impregnation is a marked con- 
gestion and hypertrophy of all the uterine structures ; changes which, 
though easily enough demonstrated after death, are not so easily ap- 
preciated during life, and are in reality of little actual diagnostic value. 
Still, the increased weight and heat of the uterus, the increased resis- 
tance in the upper and anterior wall of the vagina, — due, it has been 
said, to a slight anteversion of the womb usual at this period, — may, 
along with other symptoms, excite in the mind of the experienced 
practitioner suspicions which, under other circumstances, might not 
have arisen. 



VIII.] SUPPRESSION OF CATAMENIA. 151 

Suppression of the Catamenia is generelly the first symptom which 
attracts the attention of a woman who admits to herself the possibility 
of impregnation. Although this undoubtedly is a remarkably constant 
occurrence, it is by no means invariable. It has, however, a special 
interest, apart from its value as a sign of pregnancy, in the fact that it 
is' from the last appearance of the menstrual flow that women are in 
the habit of calculating the period at which the birth of a mature 
child will probably take place. What detracts more especially from 
its value as an evidence of impregnation, are the remarkable aberra- 
tions which, under such circumstances, not unfrequently occur. It is 
far from bejng a very uncommon occurrence that, during the early 
months of pregnancy, the catamenia, or at least a periodical sanguin- 
eous discharge, makes its appearance much as usual. Cases in which 
this occurs up to the fifth or sixth month, are of much less frequent 
occurrence; and fewer still are the instances in which, from the begin- 
ning to the end of pregnancy, the menstrual discharge apparently goes 
on as usual. Probably, Moreau is correct in assuming that, in these 
cases, the source of the discharge is not the same as in ordinary men- 
struation ; but, as regards the import of the symptom, this is a mere 
speculation, and of no practical significance. Cases are on record also 
in wdiich women menstruated only during pregnancy, menstruated for 
the first time after impregnation had taken place, or became pregnant 
without ever having menstruated at all. The last case, which is ex- 
tremely rare, is analogous to what takes place in those instances in 
which women who are nursing again become pregnant, without ever 
having menstruated since the previous accouchement. The converse 
of these cases, and what goes still further to lessen the value of the 
suppression of the catamenia as a sign of pregnancy, is to be found in 
the very numerous examples which occur in every-day practice, of pa- 
tients in whom the discharge is suppressed, as the result of certain 
morbid conditions affecting, more or less directly, the generative 
organs. A similar result may obtain, and that even more frequently, 
in those instances in which the suppression is the result of constitu- 
tional causes, in themselves apparently quite independent of the gen- 
erative functions. And, in a few rare cases, there is a suppression of 
the menstrual discharge without any appreciable cause, local or gen- 
eral ; but it cannot be doubted that in these the only peculiarity is, that 
the cause is hid from us. It should be remembered, as a fact of by no 
means very rare occurrence, that newly married women may cease to 
menstruate during several periods, as a result apparently of mere sexual 
excitement unconnected with impregnation. It is in the highest de- 
gree probable that these deviations from the normal standard, are due 
to unusual conditions of the ovary, which in one class of cases we may 
venture to assume as being unduly stimulated to attempts at ovulation, 
during a period at which that function should naturally be in abey- 
ance ; while in another class, its function is arrested by causes which 
may act upon the ovary, either specially through the generative appa- 
ratus, or constitutionally through the general system. 

The Digestive Organs are, during a pregnancy, the seat of various 
derangements of function, evidently depending on the sympathy which 



152 SIGNS OF PREGNANCY. [CHAP. 

subsists between these upon the one hand, and the womb on the other. 
Although the exact period at which such symptoms develop themselves 
varies greatly, there is scarcely a single case of pregnancy, in which, at 
some time or other, symptomatic digestive disorders do not manifest 
themselves. The most frequent of all is nausea, generally accompanied 
with vomiting, and this symptom being of much more frequent occur- 
rence in the morning than at any other time of the day, has given rise 
to the name morning sickness. 

In the absence of any special cause which might give rise to nausea 
or vomiting, and if the general health apparently remains good, this 
sign is sometimes of considerable value. It is generally, however, to 
the early months that this nausea is limited, and it usually terminates 
\J or is mitigated about the time that the fundus may be observed above 
the pubes, having commenced probably about the fourth or fifth week. 
The period of development, and the duration of this symptom, are 
subject to great irregularities ; in one case, it may be, beginning with 
the first days of pregnancy, and continuing to the last, while in others 
it does not commence until an advanced period, when local irritation 
of the stomach is more likely to be the cause. AVe have seen cases in 
which, at first, morning sickness was as marked as usual, to this suc- 
ceeded a period of immunity, extending over several months, the 
nausea returning with great discomfort to the patient during the last 
weeks, being probably due in the first instance to sympathy, and in 
the latter to the effect of proximity of the organs. Associated with 
the more familiar symptoms of morning sickness, are others which 
also have their origin in the digestive system, such as heartburn, 
pyrosis, epigastric pain, and troublesome eructations. Repugnance to 
various articles of diet, which possibly were relished before pregnancy, 
or a longing for unusual, and even deleterious or disgusting substances, 
such as occurs in chlorosis, are by no means unusual symptoms. The 
symptoms manifested during one pregnancy are no sure criterion of 
their probable form in another ; for we often find that a woman, who 
has suffered intensely in her first pregnancy from these digestive dis- 
orders, is on subsequent occasions remarkably free from them ; nay, 
it may happen that women, who have never had morning sickness, 
complain of it for the first time on the occasion of a fifth or sixth 
pregnancy. All the affections alluded to constitute, when excessive, 
morbid conditions, and as such fall to be considered as disorders of 
pregnancy. 

Salivation, although not a symptom of any practical importance, is 
occasionally so marked in degree as to constitute a prominent feature 
in the case. In this, there seems to be a special glandular sympathy 
manifesting itself in a hypersecretion, which may last during the whole 
term of pregnancy. Under the same category of phenomena which 
have their origin in the glandular system, we may here notice certain 
changes in the urine which, since the time of the ancients, have attracted 
attention as symptomatic of the pregnant state. About thirty years 
ago, a number of observers directed their attention to the investigation 
of this subject, but the person whose name is most intimately associated 
with it is M. Nauche, by whom the name Kiestein was given to the 



VIII.] CHANGES IN THE MAMM^. 153 

substance referred to. From the numerous observations which have 
been made, by him and others, it would appear that the period of 
pregnancy at which this has been discovered varies considerably ; that 
it is certainly not present in all cases of pregnancy ; and that it has 
been discovered in certain morbid conditions which have no relation 
to the pregnant state. This, of course, reduces the value of Kiestein 
as a sign of pregnancy to a low level ; but there can at the same time 
be no doubt whatever, that in a large proportion of cases the substance 
may be discovered. When the urine is fresh from the bladder, there 
is no appearance whatever which would enable us to distinguish it 
from the ordinary excretion. About the third day, or sooner, it com- 
mences to lose its transparency, and becomes hazy, as if mucus were 
suspended in it, and, shortly afterwards, distinct traces may be seen, 
on the surface, of the formation of a pellicle, which is at first thin and 
transparent, but subsequently becomes much thicker and more opaque. 
About the third or fourth day, the distinctive characters of this pellicle 
usually reach their greatest intensity, and little flocculent portions then 
commence to detach themselves from its under surface, and sink through 
the liquid to the bottom of the vessel. The whole pellicle ultimately 
goes through this process, and becomes thus transformed into a whitish 
deposit which gravitates to the bottom, as did the flocculi first detached. 
The original pellicle is then replaced by another, which contains, as 
indeed may the first one, crystals of triple phosphate; the liquid be- 
comes more turbid, until, finally, the appearances characteristic of 
pregnancy become lost in the process of putrefaction. Kiestein, then, 
first makes its appearance in the urine, under the form of a cloud, like 
cotton in suspension, which is due to the aggregation of little globules 
which exist in the urine when passed. These subsequently unite, rise 
to the surface, and constitute the pellicle which we have described. 
It is said that, when Kiestein is present in the urine, it persists from 
the end of the first month until delivery ; but the observations of 
Cazeaux throw much doubt on this assertion, as regards the last six 
weeks, for he tells us that he examined in 1849 the urine of fifteen 
women at this stage of pregnancy, without discovering any trace of it. 
Chemical and microscopical researches seem to show that Kiestein is 
a new formation, and is an azotized substance, and that it presents 
itself under the form of minute globules. Whether the theory usually 
entertained in regard to it, that it is the result of an excretory function 
of the kidneys, peculiar to the circumstances of the case, is a question 
which we must in the meantime leave in doubt; but it must be 
admitted that there are several facts firmly established in physiology, 
which, from an analogical point of view, give some confirmation to the 
hypothesis. 

Changes in the Mammce. — The Mammae are, from an early period, 
the seat of certain symptoms and changes, which are justly looked upon 
as of great importance. When we reflect on what their proposed func- 
tion is, we cannot marvel that, even thus early, they become the seat 
of changes, which are evidently designed with the view of elaborating, 
and otherwise preparing, these important structures against the time 
when they will be called upon to discharge the function in question. 



154 SIGNS OF PREGNANCY. [CHAP. 

The earliest indications which are given by the mammae of the existence 
of pregnancy, are certain vague sensations, which are described by the 
woman as of fulness and weight, but which not unfrequently amount 
to considerable uneasiness, and even acute pain. This points to the 
awakened activity of the organs, further evidence of which is soon 
shown in a considerable increase of volume, due obviously to the greater 
afflux of blood, which dates from the earliest weeks, and which mani- 
fests itself at a more advanced period, by the presence of large blue 
veins, which may be seen coursing under the skin, more conspicuously 
in women of a blonde complexion. To the touch, the gland seems 
harder than usual, and here and there may often be felt clusters of 
enlarged milk vessels, which give the impression of knotting. Towards 
the end of pregnancy, or, if the distension is extreme, at a much earlier 
period, silvery white lines are seen upon the surface of the breast, 
radiating from the nipple as from a centre. These arise from disten- 
sion of the cutaneous structures, and yielding of the corium at some 
points, so as to give facility to the expansion due to the growth of the 
gland. 

The secretion of milk in the breasts has very generally been supposed 
by the vulgar to be an infallible sign of pregnancy, either past or exist- 
ing. Nothing can be more erroneous than such a conclusion ; but, at 
the same time, the presence of milk in the ducts is, when taken along 
with other signs, often of very considerable importance. It is proper 
to mention, however, that not only is milk in the breasts no certain 
sign of pregnancy, but numerous cases are recorded by Montgomery 
and others, where the breasts of young women who had never been 
pregnant, and of old women past childbearing, have yielded milk in 
sufficient abundance to suckle a child. A striking case of this nature 
was narrated to the writer by Dr. Livingstone, the renowned African 
traveller, who had so investigated the circumstances as to eliminate 
even the possibility of doubt. A native woman was delivered of twins, 
and not being constitutionally very robust, was unable to nurse both, 
whereupon the grandmother, a woman of sixty, took one infant, when, 
after repeatedly placing it to the breast, the secretion was so abundantly 
established, that she proved an excellent nurse. Nay, more than this, 
there have been cases in which the gland in the male has secreted milk 
in considerable abundance. 

Surrounding the nipple, and circumscribed by a circle of about three- 
fourths of an inch radius from its centre, the skin presents, in the adult 
and unimpregnated condition, a peculiar' appearance, which consists 
chiefly in an increased depth of color. It is thin and delicate, and 
presents to the eye the semblance of a structure intermediate between 
skin and mucous membrane. From its surface, small glandular emi- 
nences, varying in number from twelve to twenty, or more, may be 
seen to project slightly. This area, which is called the A?-eoIa, is the 
seat during pregnancy of changes which are frequently of the greatest 
importance in strengthening the presumptive proof which may already 
exist ; but it must always be remembered that changes, closely resem- 
bling those which we are about to describe, may be produced by causes 
which have their seat in the generative system, but which are hide- 



VIII.] THE AREOLA. 155 

pendent of pregnancy ; and, moreover, that as the changes are to a 
considerable extent permanent, it is in first pregnancies that they have 
the greatest diagnostic value. The following are the appearances 
referred to: If the breast be carefully examined about the ninth week, 
a considerable increase in the size of the nipple will almost always be 
observed, this structure having become turgid, and, as it were, erect. 
Simultaneously with this, or closely succeeding it, there is a deepening 
in the color of the areola, an increase in its diameter, and a greater 
prominence and development of the follicles which stud its surface. It 
participates, obviously, in the increased vascularity of the nipple, and 
becomes, like it, moist and turgid. The alteration in color, which is 
due to this turgescence, takes place in all cases ; but it is only in women 
of dark complexion that the characteristic changes of the areola are to 
their fullest extent manifested. In these, there is an actual deposit of 
pigment, and the depth of the color is, towards the termination of the 
pregnancy, not unfrequently such as to present a most striking and 
peculiar appearance. Examination of the follicles has shown that they 
are possessed of excretory ducts, through which their secretion may, 
under certain circumstances, be expressed. 

At a period not earlier than the fifth month, there may generally be 
observed, in women in whom the areola is deep in color, some trace of 

Fie. 83. 













Areola, and secondary areola of pregnancy (seventh month). 

what Montgomery has described under the name of secondary areola, 
and to which he attaches great diagnostic significance, amounting, 
indeed, in his opinion, to a certainty of pregnancy independent of other 
signs. This secondary areola, which immediately surrounds the other, 



156 STGNS OF PREGNANCY. [CHAP. 

is, even when most distinct, very faint in color, and has been well 
compared to the effect produced by drops of water falling upon a tinted 
surface, and discharging the color. An attempt has been made in the 
accompanying cut (Fig. 83), to indicate the various appearances 
referred to. 

The pigmentary deposit, on which the appearance of the areola of 
pregnancy in a great measure depends, is not in every case limited to 
the situation in question. In a large proportion of cases, a dark line, 
about a quarter of an inch in width, may be observed running along 
the middle line of the abdomen, from the symphysis to the umbilicus, 
and occasionally extending from thence as far as the ensiform cartilage. 
A dark-colored disk, occupying and surrounding the umbilicus, was 
occasionally observed by Montgomery, and is described by him under 
the name of the "umbilical areola;" and brownish streaks, analogous 
to the silvery lines in the breasts, are not uncommonly to be seen in 
the abdominal walls, running parallel to each other, and generally 
curved, with the convexity towards the groins. These streaks lose 
their color, but do not disappear after delivery, and are therefore of 
some importance in determining the question of previous pregnancy. 
As an occasional concomitant of pregnancy, there has also been ob- 
served a more general discoloration of the skin, so much so, indeed, as 
to give rise, in one case at least, to the suspicion of existing disease of 
the suprarenal capsules. In the case in question, the whole forehead, 
and part of the cheeks, neck, and breast, were deeply tinged of a yel- 
lowish-brown color; but within a few w r eeks after the birth of the 
child this had completely disappeared, nor was there at any time the 
slightest symptom, in addition to the discoloration, to encourage the 
belief in the existence of the disease of Addison. In other instances, 
discoloration of the skin during pregnancy has been found to be due 
to the presence of 'pityriasis versicolor. 

The appearance of the abdomen, although a very conspicuous sign of 
pregnancy, can only be admitted as such on the careful exclusion of 
certain sources of fallacy. For not only may solid tumors of various 
kinds give rise to appearances very similar, but fluid accumulations, 
such as ovarian cysts or dropsical effusions, or even distension of the 
bladder, may delude the unwary into a hurried and erroneous diagno- 
sis. It behooves the observer, therefore, to be careful how he admits 
this point in evidence. Cessation of the menses, with abdominal en- 
largement, would almost certainly be admitted by an expectant mother 
and her friends as proof sufficient ; but it sometimes falls to the duty 
of the medical attendant to dispel such illusions. Passing over, for the 
moment, the evidence to be derived in such cases by the practice of 
palpation, a certain amount of information may be obtained by the eye 
alone, in examining the abdomen in the various stages of pregnancy. 

As we have already seen, the uterus, during the early w r eeks of 
pregnancy, instead of rising upwards, into the abdominal cavity, actually 
falls downwards towards the floor of the true pelvis. This fact gives 
rise to the earliest modification in the outline of the abdomen, which 
consists, not in an enlargement as might have been expected, but in a 
dragging downwards of the umbilicus, and a flattening of the hypogas- 



VIII.] EXTERNAL APPEARANCE OF ABDOMEN. 157 

trie region. This fact has been long recognized, and, although its im- 
portance has been exaggerated, its expression is embodied in the old 
French proverb, quoted by all writers, " Ventre plat, enfant il y a.' 7 
Actual abdominal enlargement dates from about the thirteenth or 
''fourteenth week, but so much depends upon the figure of the woman, 
the number of children she has borne, the presentation of the child, 
and the quantity of liquor amnii, that the mere study of the abdominal 
outline would, in so far as uterine development is concerned, rarely 
afford us reliable information. Another observation which should be 
made, consists in a careful examination of the umbilicus. During the 
first three months, the depression of the navel is, if altered at all, some- 
what deeper than usual. On the expiry of this period, it regains its 
original appearance. In the course of the fourth month, it becomes 
less hollow than before conception, and, from this time, the depth of 
the cavity becomes gradually diminished until, about the seventh 
month, it becomes completely effaced, and is on a level with the sur- 
rounding skin. Nor do the changes of the umbilicus cease here, for 
during the two last months the umbilicus protrudes beyond the sur- 
face, being, as it were, inverted by the pressure which is brought to 
bear on the inner surface of the abdominal wall by the distending womb. 
This is a pretty constant sign, and is certainly the most important to 
be derived by an ocular observation of the abdominal wall ; but simi- 
lar phenomena may be caused by ascites and tumors. 

In so far as external appearance is concerned, there is scarcely any 
variety of solid tumor connected with subjacent organs, nor even any 
tumor, due to fluid or gaseous distension, which may not, under cer- 
tain circumstances, give rise to the suspicion of pregnancy. It is rarely, 
in practice, that the differential diagnosis of such affections presents 
any great difficulty; but there are cases in which difficulties undoubt- 
edly exist, when recourse must be had to percussion and palpation, to 
remove such doubts as may arise. Such an examination enables us to 
determine the shape and limits of the tumor, and the relation which 
it bears to the bowels and other surrounding parts. Nothing is here 
of such importance as the consistency of the tumor. The extreme 
hardness of uterine fibroids, on the one hand, and the yielding softness 
of gaseous or fluid distension on the other, represent the extremes; 
between which endless varieties exist. But the uterus, when distended, 
communicates to the hand a feeling so peculiarly its own, as to enable 
any one possessed of the requisite tactus eruditus to pronounce on the 
subject almost with certainty. This feeling consists in a certain elasticity 
which, although it may be simulated, is different from that which is 
communicated by any other form of abdominal tumor. Besides this, 
the practice of palpation seems, in some cases, actually to cause a cer- 
tain amount of feeble, painless contraction in the womb, which, when 
distinctly felt, is of the highest diagnostic value ; but it must be re- 
membered that these symptoms prove only that it is the uterus which 
we are touching, and are no evidence of pregnancy. If, however, we 
are convinced that the elastic tumor contains a solid movable body, 
there is scarcely any room for doubt. In cases where, from unusual 
thickness of the abdominal walls, or from some other cause, palpation 



158 SIGNS OF PREGNANCY. [CHAP. 

gives obscure results, the history of the tumor, and, especially, the 
situation in which it was first observed, are points which may have 
special value. If ovarian, the tumor will have been observed, in the 
first instance, in either groin ; if from the spleen or liver, the history 
will be of a growth developing from above downwards, instead of the 
globular uterine swelling, first observed in the middle line behind the 
symphysis, which steadily increases in an upward direction, and the 
nature of which is probably revealed by other important symptoms, 
some of which have already been detailed. In those cases, in which 
the tumor is proved to be the uterus — but the fact of pregnancy is still 
in doubt — there is always the possibility of the cavity being distended 
by other contents, such as intra-uterine polypi of various forms, dis- 
tension of the cavity with gas (physometra), or a similar fluid disten- 
sion (hydrometra). Actual difficulty, even in exjjerienced hands, and 
error in diagnosis, are most likely to occur in those cases in which 
pregnancy coexists with some of the morbid affections above alluded 
to. We may have, for example, clear evidence of ovarian disease — a 
tumor, Ave shall suppose, partly cystic and partly solid, springing from 
either groin, and slowly increasing in size. In such an instance, on 
the occurrence of pregnancy, the abdominal tumor will increase with 
much greater rapidity ; but, one cause of abdominal enlargement 
having already been established, the possibility of a coexisting cause 
may quite slip out of notice, and thus very serious mistakes have, 
in some cases, actually been made. When we come to consider the 
diseases and complications of pregnancy, we shall find that there are 
many other morbid conditions which, when associated with it, tend 
greatly to obscure the diagnosis. 

Vaginal Examination. — Important information, either positive or 
negative, is afforded at all stages of pregnancy by a vaginal examina- 
tion. In the early months, the descent of the uterus causes an appar- 
ent shortening of the vagina, and an increase in its width from side 
to side ; but from the end of the third month till towards the end of 
gestation, — when, as we shall see, the womb again falls downwards, — 
the extension of the vagina upwards results in an elongation and a 
consequent proportional narrowing of its diameters. There is clear 
evidence here also of increased activity of the circulation, correspond- 
ing to that which we have found to exist in the internal genital organs. 
It takes the form^ in this situation, of a venous engorgement, which is 
due, in part at least, to obstruction, caused by pressure of the gravid 
womb, and is indicated by a more or less livid color of the mucous 
membrane — very different from the rose color of the unimpregnated 
state. This ocular examination of the parts, although it may thus 
reveal a sign which is far from being the least important, is, for obvi- 
ous reasons, a method of research which cannot be generally adopted 
in the practice of midwifery, so that we have to depend here upon the 
results which are afforded by an examination conducted, under the 
bedclothes, by the finger. 

Under the head of digital examination, the first symptom which 
often comes under our observation is one which is due to the increased 
vascularity of the parts to which reference has just been made, and 



IX.] CHANGES IN THE CERVIX UTERI. 159 

consists in strong pulsations, which are obviously due to enlargement 
of the vaginal arteries. This, which is a sign of no great importance, 
has been described by Osiander under the name of vaginal pulse. During 
the later months, it is by no means unusual to find the mucous mem- 
brane hypertrophied and covered with small granulations or papillary 
projections, which are supposed to be the result of an abnormal devel- 
opment of the mucous follicles, and which are, certainly, often accom- 
panied by an augmented mucous secretion. The chief, and in many 
cases, the sole object of vaginal examination is to ascertain the condi- 
tion and anatomical relations of the inferior segment of the uterus ; 
and, more especially, the state of the os, and of that portion of the 
cervix which projects into the vagina. In those early weeks, during 
which the uterus descends within the cavity of the true pelvis, the 
descent is accompanied by a certain amount of anteversion, which ena- 
bles the experienced accoucheur, as early as the sixth week, to recognize 
in the anterior vaginal cul-de-sac a fulness or slight resistance, which 
is absent in the normal and un impregnated condition of the parts. As 
pregnancy advances, this becomes more distinct, although higher, until 
the most depending part of the fcetus can be distinctly felt through the 
anterior uterine wall. 



CHAPTER IX. 

SIGNS OF PREGNANCY (Continued). 

CHANGES IN THE OS AND CERVIX UTERI: PROGRESSIVE SOFTENING OF: CHARAC- 
TERS OF AT VARIOUS STAGES — POSITION OF OS IN RELATION TO PELVIC 
WALLS — PRACTICE OF THE "TOUCHER" — EXAMINATION PER ANUM — QUICK- 
ENING: FCETAL MOVEMENTS OBSERVED; (a) BY THE MOTHER, (b) BY THE 
ACCOUCHEUR — BALLOTTEMENT OR REPERCUSSION — FCETAL PULSATION — FUNIC 
SOUFFLE — UTERINE SOUFFLE : THEORIES AS TO ITS PRODUCTION — STETHO- 
SCOPIC EXAMINATION OF FCETAL MOVEMENTS — SIGNS DIVIDED INTO CERTAIN 
AND PROBABLE — TABULAR RESUME OF THE SIGNS OF PREGNANCY. 

It is from the observation of the Os and Cervix Uteri that the 
most important information is derived in the course of a vaginal exam- 
ination ; for not only does this give us indications of pregnancy at a 
very early stage, but it enables us in many instances to judge, proxi- 
mately at least, of the stage which the pregnancy has attained. From 
a very early period of gestation, a difference takes place in the firmness 
and resistance of the cervical tissue, which is due, in the first instance, 
to the congestion and hypertrophy of which this, as well as the other 
portions of the uterus, are, immediately after conception, the seat. But 
in addition to this, there is a special change, which a few careful exami- 
nations by the finger will enable any one to recognize, and which is 
admirably described by Cazeaux. " Towards the end of the first 
month, " he says, " one may already discover that, in addition to the 



160 SIGNS OF PREGNANCY. [CHAP. 

first general modification, that portion of the lips of the os which is 
situated most inferior] y, or rather most superficially, begins to soften. 
This appears to be rather an oedematous condition of the mucous mem- 
brane, than an actual softening of the tissue proper of the lips, so that, 
in pressing slightly upon the thick and softened membrane, the finger 
at once perceives its fungous softness, but seems immediately after- 
wards to reacli the tissue proper of the neck, which still retains its 
normal consistence. The sensation thus conveyed closely resembles 
that which we obtain if we press with the finger upon a table, which 
is covered with a thick and soft cloth. It is not till towards the ter- 
mination of the third month, or the beginning of the fourth, that the 
entire thickness of the lips of the os is softened, to the extent of two 
or three millimetres. From the fifth month, the softening extends 
from below upwards, and, at the sixth, reaches the centre of the vaginal 
portion of the cervix. During the three last months, it invades, step 
by step, the superior part, until it reaches the internal os, so that at 
the end of pregnancy, the neck is so soft, in the case of certain women, 
that I have often observed that students had great difficulty in dis- 
tinguishing it from the walls of the vagina." This, according to the 
distinguished accoucheur, from whom we have quoted, should be looked 
upon as a very important sign of pregnancy, and is very constant in 
its occurrence, unless it be in cases where the tissue of the cervix is 
the seat of pathological alterations. 

The shape of the os and cervix also undergoes, during the advance 
of pregnancy, some very remarkable changes. The os very early loses 
the form of a transverse slit, and becomes more circular in form, while 
the comparative softness of the tissue admits sometimes of the intro- 
duction of the point of the finger. This becomes much easier as preg- 
nancy advances ; and the softening process described by Cazeaux ex- 
tends, so that, by the sixth month, it is occasionally possible, even in 
primiparse, to introduce the point of the finger. A reference to the 
diagram already shown (Fig. 82, p. 147) indicates the manner in which, 
according to the ideas originally entertained by Desormeaux, and by his 
followers to the present day, the canal of the cervix becomes invaded, 
in the march of development, by a process of encroachment from 
above downwards, dating from the sixth month, or, according to some, 
even earlier. Nothing, we may say, could be more simple or more 
easy of comprehension, than this process of invasion according to a 
fixed and definite law. 

It requires, however, no very extensive study or observation of the 
facts to show that no such simple description will afford a satisfactory 
explanation of the facts as they come under observation in practice. 
A shortening, or apparent shortening, of the vaginal portion of the 
cervix is, more especially in primiparse, undoubted ; but are we enti- 
tled to accept this observation as conclusive, or even as corroborative, 
evidence of the views of Desormeaux ? No one, we should imagine, 
can hesitate, on reflection, to answer this query in the negative ; but 
yet we can scarcely doubt that this has been accepted by many as suffi- 
cient evidence of the doctrines to which they subscribe. 

This theory, although so convenient in its simplicity, is one which 



IX.] CHANGES IN THE CERVIX UTERI. 161 

many writers both of the past and the present century have found it 
impossible to adopt ; but, unfortunately, of the dissenters, no two seem 
to have reached precisely the same conclusions. In fact, this, so far 
from being a simple matter which admits of clear demonstration by a 
few strokes of the pencil, is at the present day a subject which urgently 
requires renewed and careful examination. In rejecting, as we may 
safely do, the theory of Desormeaux as applicable to all cases, it still 
remains for consideration whether it is applicable to any case whatever. 

In reviewing the observations of those who, at different epochs, have 
formed opinions hostile to the views commonly entertained, among 
whom we may mention Weitbrecht (1750), Stoltz (1826), and Matthews 
Duncan (1868) — one thing becomes abundantly clear, that no single 
description will serve for all cases ; and another becomes scarcely less 
obvious, that the process in pluriparse differs materially from that in 
the case of primiparaa. The softening process above described, involv- 
ing, as it necessarily does when complete, the disappearance of the 
characteristic hardness and resistance of the vaginal portion of the 
cervix, alters so thoroughly, in so far as the sense of touch is con- 
cerned, the apparent anatomical relations of the parts, that we must 
recognize in this, at least, a possible source of error. Stoltz and 
Cazeaux suppose that the shortening of the canal of the cervix takes 
place without any yielding of the os internum, the os internum and os 
externum being approximated in consequence of the softening of the 
tissues. In other words, they suppose that the width of the canal of 
the cervix is increased at the expense of its length ; but as this idea is 
somewhat fanciful, we need not dwell upon it. The figures here given 
represent the views which, at the present day, are being generally 
accepted, and are borrowed, with slight modifications, from Schultze. 

In so far, then, as primiparse are concerned, the views of Schultze 
seem to confirm those of Desormeaux, except that the latter believed 
the invasion of the cavity of the cervix to date from a still earlier 
period. In Figs. 84, 86, and 88, the conditions indicating the primi- 
paraB os are clearly indicated ; but, as regards the period at which the 
resistance of the os internum is first overcome, the researches of Stoltz, 
and the more recent observations of Matthews Duncan, not only throw 
doubt on the views formerly entertained, but go a long way to disprove 
them. Indeed, the belief is now steadily gaining ground that, even in 
primiparse, it is only during the last fortnight that the encroachment 
upon the canal of the cervix takes place, Duncan, indeed, believing 
that its dilatation is only effected by the painless uterine contractions 
of the last few days of pregnancy. 

Practical investigation of the matter is unfortunately beset with no 
little difficulty, for not only are the opportunities of post-mortem ex- 
amination few, but the circumstances are such, in most cases, as to 
render crucial observations in the living subject impossible without the 
risk of inducing premature labor. Our belief is that all cases do not 
follow the same law ; but we have had no difficulty in convincing our- 
selves that, even in the last days of pregnancy, when the feel of the os 
externum and the apparent proximity of the presenting part w T ould 
seem to imply that the entire canal of the cervix was lost, there some- 

11 



162 SIGNS OF PREGNANCY. [CHAP. 

times exists a canal between the os externum and a point considerably 
higher, a canal which crosses from before backwards the axis of the 
presenting part, so as to give one the idea of a valvular opening into 
the uterine cavity. It is proper to add that dissections and drawings 
from nature seem to corroborate this view. 

As regards the process in pluriparse (Figs. 85, 87, and 89) there is 
less difference of opinion, and we find that the ideas entertained by 
Schultze, and represented in the diagram referred to, differ very little 
from those promulgated by Stoltz and Cazeaux, and corroborated by 
the more extreme views of Matthews Duncan. The softening process 
attacks the tissue of the cervix in a manner precisely similar to that 
which obtains in the case of primiparae. There is in this case, how- 
ever, a gaping external orifice, which admits easily, even earlier than 
the twenty-fourth week, the point of the finger. From this period 
onwards, till about the thirty-sixth week, the only change which takes 
place is, that the cavity of the cervix becomes more and more accessible 
to the finger, which slips into it, as Cazeaux says, as into a thimble. 
The mechanical effect of previous pregnancy seems to be that the 
cavity proper admits of easy and ample distension, so that no call is 
made upon the cavity of the cervix until the termination of pregnancy 
approaches. Even in those instances in which the cavity of the cervix 
is most easily permeable by the examining finger, the os internum is, 
in pluriparae, often found quite impassable at the thirty-seventh week, 
or even later. From this period, however, a very rapid shortening of 
the cervix takes place until, at the fortieth week, as in primiparae, the 
cervix is in a manner effaced. But there remains to the last, instead 
of the thin, smooth, and almost membranous margin of the os in primi- 
parae, an irregular nedematous lip which is in the highest degree char- 
acteristic, and which is not wholly lost even during the first stage of 
labor. There is represented in the diagrams (Figs. 85, 87, and 89) — 
which may be compared with the adjoining figures — the distinguishing 
features of the pluriparous os, as observed from the vagina. 

The description, then, which is usually given of the state of the os 
during the various stages of pregnancy is applicable only to the case of 
those within whom a foetus is, for the first time, being developed. Rapid 
as is the process by which the uterus is reduced in size after delivery, 
it never completely regains its virgin state. The os and cervix are the 
parts which show most distinctly the peculiarities which attach to those 
who have already borne children; and, in the course of a digital 
examination, this peculiar feature comes prominently under our notice. 
This method of examination, therefore, enables us not only to recognize 
the stage of the pregnancy, but also to distinguish between first and 
subsequent pregnancies — due regard being had to the manner in which 
the cervix is developed in the two classes of cases. 

The situation of the os uteri, relatively to the walls of the pelvis, is 
another point which is disclosed in the course of a vaginal examination. 
This is, however, of more importance in conveying information as to 
the stage of pregnancy than in regard to the fact of its existence ; but, 
as it may, under certain circumstances, become an important point in 
evidence, its omission here would be improper. We have already seen 



IX.] 



CHANGES IN THE CERVIX UTERI. 



163 



that, in consequence of the growth downwards of the uterus, the os is, 
in the first instance, displaced in the same direction ; and, as we believe, 
somewhat backwards, this movement corresponding to the slight ante- 

DlAGRAMS SHOWING THE KELATION WHICH THE CANAIi OF THE CERVIX 

bears to the cavity of the uterus during pregnancy. 
(After Schultze.) 



Primipar^e. 
Fig. 84. 



PLTJRIPAR.E. 
Fig. 85. 





Twenty-fourth week. 



Fig. 86. 



Fig. 87. 





Thirtieth week. 




At full term. 



flexion to which reference has already been made. The escape of the 
uterus from the true pelvis, and the subsequent and rapid upward 
development of its body, soon causes a corresponding movement upwards 



164 SIGNS OF PREGNANCY. [CHAP. 

of the os, which thus seems to follow the fundus, in proportion to its 
development, steadily upwards in the pelvis from the tenth to the 
thirty-seventh week, when it attains the highest point, and is reached 
by the finger sometimes with a little difficulty. With the descent of 
the uterus in the last weeks, it again sinks downwards, and, at the same 
time, moves backwards ; so that, though lower, it is not more within 
reach of the finger. This final movement corresponds to the falling 
downwards and forwards of the fundus, mention of which has already 
been made. Sometimes the head descends to an unusual degree in the 
pelvis, and, in such cases, may push before it the anterior segment of 
the uterus. From this cause a difficulty occasionally arises, which may 
even give rise to the suspicion of congenital absence of the os ; but a 
careful examination by the finger, in the direction of the hollow of the 
sacrum, will rarely fail to disclose the position of the os — the difficulty 
being, of course, greater in first than in subsequent pregnancies, owing 
to the membranous thinness which the lips of the womb frequently, in 
these cases, assume. 

In the practice of the toucher, or digital examination of the vagina, 
skill and experience are of paramount importance; and as it is by 
practice alone that the required dexterity can be attained, it behooves the 
student to avail himself of every opportunity which may arise for add- 
ing to his store of experience. With this view, some uniform scheme 
or method of examination should be adopted. A long finger is doubt- 
less an advantage, but the advantage is by some writers greatly exag- 
gerated. The index finger may alone be used, but some prefer to use 
two, by which we no doubt gain something by the greater length of 
the second finger. This advantage, however, is frequently counter- 
balanced by the increased pain which the examination gives the woman, 
causing her to shrink and draw away from the hand of the accoucheur. 
The finger should be passed forward from the situation of the coccyx 
over the anus and the posterior commissure of the vagina. It may 
seem almost too ridiculous to suppose that the anus should in such an 
examination be mistaken for the vagina, but the knowledge of the fact 
that the mistake has been committed will suffice to prevent the student 
from a similar error. The finger should be well oiled or smeared with 
lard, with the object in all cases of facilitating introduction, and in a 
certain class of cases to protect the finger. Notice is to be taken, as a 
matter of routine, of the state of the perineum, labia, and other parts. 
The condition of the vagina and rectum, and of the pelvic walls, must, 
in like manner, not be overlooked, for, in all questions bearing upon 
pregnancy, the state of these parts must have a special interest, and the 
timely recognition of anything abnormal may have the effect of avert- 
ing a calamitous result. In the actual examination of the os and cervix, 
some assistance will occasionally be derived from the use of the hand 
over the surface of the abdomen, by which the fundus may be steadied 
and the os pressed downwards more within the reach of the finger. 
In conducting such investigations as we have been referring to, the 
strictest caution must in every instance be exercised in order to obviate 
the possibility, which exists in every case, of premature labor being 
induced bv rude and careless hands. The amount of irritation neces- 



IX.] MOVEMENTS OF THE CHILD. 165 

sary to excite the uterus to contraction varies greatly in different cases, 
but we cannot doubt that incautious interference, more especially with 
the os and cervix, may incite contraction, and cause the loss of the 
product of conception. 

In the investigation of uterine diseases unconnected with pregnancy, 
it is often proper to institute an examination per anum. In the prac- 
tice of midwifery, and the diagnosis of pregnancy, such a mode of ex- 
amination is very seldom necessary. Cases, however, do now and 
again occur, in which, owing, it may be, to excessive tenderness of the 
parts, or to partial obliteration of the vagina, the result of sloughing, 
we may be obliged to have recourse to this expedient. Or, again, it 
may be necessary for the proper examination of tumors, which exist as 
complications of pregnancy, and which are connected with the poste- 
rior part of the pelvis. And, in one other group of cases, we are 
recommended by Montgomery to examine thus, " when, for any par- 
ticular reason, it is thought desirable to ascertain whether the uterus is 
enlarged within the first two months of supposed pregnancy/ 7 Under 
any circumstances, however, this mode of examination is so repulsive 
to the woman that, with that consideration for her feelings which should 
always sway us, we instinctively shrink from proposing it, unless the 
circumstances be such as to render it absolutely essential. 

Quickening. — The period of quickening is that at which the mother 
becomes for the first time conscious of the movements of the foetus 
within her womb. They who at one time believed that the ascent of 
the uterus from the pelvis to the abdominal cavity took place suddenly, 
and was not a simple process of gradual evolution, held, naturally 
enough, the view that the quickening was this assumed sudden motion. 
Every woman now knows that it is due to the actual movements of the 
living child, which are at this period first communicated to her senses. 
The sensation, however, does not represent the first movements of the 
child, for they are seldom perceived by the mother earlier than the 
sixteenth week, whereas, in abortions at a much earlier period, vigor- 
ous movements are often observed after the expulsion of the embryo. 
Nor is it an uncommon thing, in the course of an abdominal examina- 
tion by the hands and the stethoscope, to feel or to hear slight move- 
ments which we can only suppose to be exercised by the foetus, and 
that too at a time when the mother may still be in doubt as to the fact 
of her pregnancy. 1 The time usually stated as that of quickening is 
about the middle of pregnancy, or four and a half calendar months. 
This belief, although only a popular one, is sufficiently wide of the 
truth to call for correction. It is difficult, however, to fix upon a 
period as a safe average, as we know that the time of quickening may 

\ It is now generally believed that the mother cannot be conscious of the foetal 
movements until the uterus comes in contact with the abdominal walls. It is then 
for the first time possible that the sensation can be transmitted by sensory fibres of 
the cerebrospinal system ramifying: in the abdominal parietes. This theory ac- 
counts, as it appears to us, quite satisfactorily, for the phenomena which exist ; for 
we cannot doubt that the limbs of the child must strike the uterine walls at an 
earlier period than they are perceived by the mother, and it is not to be expected 
that the sensation could be communicated through the few filaments which reach 
the uterus from the cerebrospinal system, as these are confined to the os and cervix. 



166 SIGNS OF PREGNANCY. [CHAP. 

vary from the end of the second to the eighth month. In a very large 
majority of cases, about the seventeenth week may be assumed as the 
period at which women feel the first feeble flutterings which to them 
indicate the vitality of their offspring. In some instances, the move- 
ment is more decided, even at this time, but the rule is that it is at 
first very faint, and gradually becomes stronger in proportion as the 
development of the foetus progresses. In the later months, the foetal 
movements become so vigorous, that they may cause the woman actual 
pain, and have been known to cause her to cry out; and, at this stage 
of pregnancy, the movements which are perceived are due to brisk 
flexion and extension of the joints of the lower limbs, the sensation 
being in some instances due to smart kicks, and in others to a continu- 
ous movement, such as might be caused by the passage of the knee 
along the inner uterine wall. Important as this sign is to the accou- 
cheur, and all-important as it is to the woman, it is nevertheless one 
in regard to which we must always be cautious, as there are fallacies 
which may lead astray even those women who have previously borne 
children, and who may thus be supposed to be familiar with the sen- 
sation in question. The conditions which may give rise to such erro- 
neous impressions are rapid movements of gas in the intestines, irregu- 
lar contraction of the muscles of the bowels, or even of the muscles 
which form part of the abdominal walls; and the pulsatile movements 
of an aneurism, or of a large artery, which, being communicated to a 
tumor within the abdomen, may very readily deceive a woman who 
already suspects that she is pregnant. Such cases are so frequent, that 
we must always be careful in receiving as evidence the mere statement 
of the woman. 

We have hitherto spoken only of the active movements of the foetus, 
as observed by the mother. But these movements receive, as evidence 
of pregnancy, a vastly increased significance, if, in addition, the accou- 
cheur is able to convince himself of their reality, which he generally 
can succeed in doing by careful abdominal palpation. The nature of 
the tumor, its symmetry, and its elasticity, will already have prepared 
him for the corroborative evidence which he expects, and a very ordi- 
nary skill will prevent him from being misled by any disturbing influ- 
ences, such as may deceive the woman. He is conscious of the presence 
under his hand of a solid body, contained within an elastic tumor. Pie 
presses this body from side to side, and in various other directions, 
with the almost certain effect, if the child be alive, of causing such 
movements as, from the fifth month onwards, will place the question 
of pregnancy beyond the possibility of doubt. His eye, meanwhile, 
may follow many of the more violent of these movements, the abdominal 
wall forming from time to time distinct projections, corresponding to 
the subjacent portion of the limb or body of the foetus, so that the out- 
line of the abdomen is for the moment distorted, the projecting part 
often suddenly changing its site before it sinks dovm again within the 
liquor amnii. But even here we are not safe from error, as, in some 
instances, movements closely resembling those of pregnancy have been 
observed by the accoucheur. The only condition, how r ever, which 



IX.] BALLOTTEMENT. 167 

might mislead any one using ordinary care, is that which arises from 
spasmodic action of the abdominal muscles. 

An interesting example of this occurred several years ago in the 
Glasgow Royal Infirmary, in one of the wards at that time under the 
care of the writer. This woman was thirty -two years of age. She had 
been married for several years, but had had no children. She had been 
admitted on account of bronchitis, and was highly hysterical. She 
stated that she was pregnant, an assertion which at first attracted little 
attention, but as she stated subsequently that she had been pregnant 
for fourteen months, the case was looked upon with some interest by 
the gentlemen attending the clinique. The symptom upon which she 
founded her belief was the motion of the child, which she said she felt 
frequently and quite strongly. On examination, a tumor was observed 
in the abdomen, somewhat to the left of the middle line, reaching as 
high as the umbilicus, and not at all unlike the gravid uterus at the 
sixth month. When the hand was placed over this and held steadily 
for a little, distinct jerking movements were noticed, which, for the 
moment, seemed to have some resemblance to such as might be caused 
by a foetus in utero. A little further examination soon showed the 
true nature of the case ; the tumor was tympanitic on percussion, and 
nothing like the outline of the uterus could be felt; the os, on vaginal 
examination, was found to have none of the characteristics of preg- 
nancy ; the stethoscope gave a negative result. And to make things 
certain, the woman was put under the influence of chloroform, when 
the tumor completely disappeared, and the suspicious movements 
ceased. The case w r as one of " phantom tumor," with spasmodic con- 
traction of the abdominal muscles; but no amount of reasoning could 
shake the patient's belief in her pregnancy, and she left the hospital 
in the full conviction that she was sixteen months gone with child, 
and that in the course of the succeeding month she would give birth to 
a child in an unprecedented condition as to development. 

Ballottement. — An important sign of pregnancy is also to be found, 
under certain special conditions, in the passive movements which may 
be imparted to the foetus. This sign has been called by some English 
writers " Repercussion," but is more familiarly known under the French 
designation " Ballottement," which is certainly the more appropriate 
of the two. The following is the manner in which this test is usually 
applied : The woman is placed in a position which is intermediate 
between reclining and standing, and a very convenient plan is to have 
her shoulders supported behind, while she sits on the edge of the bed, 
with her feet upon the ground. The fundus uteri is then steadied by 
one hand, while the index finger of the other is introduced in the usual 
way into the vagina, with the palmar surface upwards. The finger 
thus placed is then brought into contact with the anterior segment of 
the uterus, near the cervix, where the presenting head of the child will 
generally be most easily felt. A smart jerk is given upwards, and the 
finger then kept perfectly steady, in its original situation, when, if the 
attempt be successful, it will be found that the foetus, which had risen 
up in the liquor amnii, in obedience to the impetus which had been given 
to it, falls, in a few seconds, back into its original place, and seems to 



168 SIGNS OF PREGNANCY. [CHAP. 

poise itself upon the tip of the finger, communicating to it the peculiar 
sensation from which the test derives its name. 

Although the posture above indicated is that in which the sign of 
ballottement is most readily recognized, it is by no means the only 
position in which it may be made out. A precisely similar sensation, 
indeed, is communicated when the woman lies upon her back, or even 
(although more rarely) when she occupies the ordinary obstetrical 
position on the left side. The same effect may also be produced in the 
course of abdominal palpation, about the fifth or sixth month, when, 
if the woman is placed upon her side, in the horizontal position, and 
one hand passed beneath the projection, there will be felt, if the ab- 
dominal walls are not too thick, some portion of the body of the foetus 
resting upon the hand. This, not un frequently, may be displaced, and 
will return upon the fingers precisely in the same manner, and on the 
same principle, as when the examination is conducted in the usual way. 1 

The sign of ballottement establishes the presence, in a fluid medium, 
of a solid body. This body must obviously be, on the one hand, of 
sufficient size to be perceptible to the sense of touch, and on the other, 
of a size considerably less than the cavity which contains it. It is 
clear that, unless these conditions are fulfilled, the sign is not available 
for the purposes of diagnosis. Of this proposition it is an obvious 
corollary, that it is only during a certain period of a pregnancy that 
ballottement can be distinguished. Before the fourth month, the size 
of the embryo is so small that it is impossible to produce the move- 
ment; but from this epoch till about the seventh month, it becomes 
more and more distinct. For a few weeks after this it may still be 
observed, although with greater difficulty ; but, during the last six 
weeks, this method of examination gives no result whatever, in con- 
sequence of the great size of the child, and the extent to which the 
uterine cavity is filled by it. For a similar reason, it is not available 
in twin pregnancy. The only exceptions to this rule are cases in which 
the quantity of liquor amnii is greater than usual. Ballottement, in 
the hands of an experienced practitioner, may be looked upon as a 
certain proof of pregnancy; but by the inexperienced it is never to be 
relied upon, without strong corroborative evidence of some kind. The 
conditions requisite for its production are all fulfilled, it must be re- 
membered, in the case of calculus in the bladder, when the solid body 
may be displaced with ease in its fluid medium. Anteversion of the 
womb, too, has, on a hurried examination, given rise to sensations 
closely resembling those of ballottement. In admitting, therefore, that 
ballottement is a certain sign of pregnancy, we do so, we repeat, with 
the reservation that it is so in experienced hands alone. 

Foetal Pulsation. — By far the most important of all the signs of preg- 
nancy, is that which is associated with the name of Mayor of Geneva, 
who was the first to discover that the heart of the foetus could be heard 

1 Considerable attention has been given of late } T ears, more particularly on the 
Continent, to the importance of abdominal palpation in the diagnosis of pregnane}' ; 
and there is no doubt that in this way, and under favorable circumstances, the pre- 
sentation, and even the position of the child may, with tolerable accuracy, be ascer- 
tained. 



IX.] FCETAL PULSATION. 169 

beating through the abdominal and uterine walls. This discovery was 
announced in 1818, but attracted little notice until several years later. 
The period at which these sounds become audible in the course of preg- 
nancy, is subject to considerable variation. It is certain that, as a 
general rule, it is not till the fifth month that they can be detected ; 
but many trustworthy observers have asserted that they have heard 
them in the course of the fourth month, and even as early, in some few 
cases, as the eleventh week. This latter statement is generally looked 
upon with incredulity ; but there can be no doubt but that occasionally 
the sounds may be heard in the fourth, third, or second, or even in the 
first week of the fourth month. On an average of a large number of 
cases, the eighteenth week may be stated as about the period at which 
we may expect to hear it. 

These pulsations are much more frequent than those of the mother, 
and are, like them, distinctly double. They, of course, lack the volume 
of the maternal sounds, and are further enfeebled by the distance from 
the ear, and by the low density of the intervening media. The fre- 
quency of the beats is increased by the foetal movements, and may thus 
be found to vary at different times ; but it generally ranges from 130 
to 160 in a minute. Some interesting observations made by Steinbach 
and Frankenhauser seem to show that the heart's action is more rapid 
in females, in the proportion, as they say, of 144 to 131. The pulse 
of the mother has no marked influence upon that of the child. It is 
scarcely possible, therefore, for any one who takes note of this frequency 
in the beats, to mistake them for maternal pulsations, which might, of 
course, under various anatomical and pathological conditions, be pro- 
duced in any tumor under examination. The only case in which the 
possibility of difficulty can be admitted is where the maternal pulse is 
unduly accelerated by the existence of fever, or by some more transient 
cause ; so that, in practice, it is well to adopt the simple precaution of 
placing the finger upon the mother's wrist at the moment we are mak- 
ing the stethoscopic examination, when, if there is obvious dichronism, 
we are sure of our diagnosis ; while, on the contrary, if there is an ap- 
proach to synchronism in the two pulses, caution is clearly indicated. 

The pulsation of the foetal heart is never heard over the whole sur- 
face of the abdomen, but, on the contrary, over an area which is always 
limited. This site varies with the presentation and position of the 
child, and it is often only after prolonged exploration that a point is dis- 
covered where the sounds are clearly audible ; and, as w T e have already 
shown that the presentation of the child is more constant the nearer 
it is to the end of pregnancy, it follows that the earlier the period at 
which the examination is conducted, the greater will be the variety in 
the site at which auscultation has a successful result. It is usual, with 
a view" of saving time and trouble, to adopt a uniform plan in conduct- 
ing this investigation, beginning always at the point at which the 
sound, for well-known reasons, is most frequently to be distinguished. 
The child, as is known, lies in the womb, in a very large majority of 
cases, with the head downwards, and the back forwards and to the left, 
some portion of the back part of the trunk being thus brought into 
contact, almost invariably, with the uterine wall, somewhat to the left 



170 SIGNS OP PREGNANCY. '[CHAP. 

of the middle line. If we place the stethoscope over any portion of 
the uterus other than this, the layer of amnionic fluid which lies be- 
tween our ear and the heart of the foetus cuts off all acoustic commu- 
nication ; whereas, at the point just named, there is continuity of solid 
tissue, and through that the sound is conducted. The extent of the 
area over which the sounds are heard depends, in a great measure, on 
the quantity of the liquor amnii, being greatest when it is scanty, while, 
with much liquid, a small portion only of the foetal trunk comes into 
contact with the uterine wall, and the area is thus proportionally 
small. The point, therefore, at which we have the best chance of at 
once catching the sound, is about midway between the umbilicus and 
the symphysis pubis, and somewhat to the left side. If the child is in 
what will be described afterwards as the second cranial position, the 
back being thus forwards and to the right, we may expect to hear the 
sound at a corresponding point to the right of the middle line. In 
dorso-posterior positions, whether of the head or of the breech, the 
convexity of the spinal column being turned backwards sometimes con- 
stitutes a difficulty in auscultation, as is also created by an unusual 
quantity of the liquor amnii (dropsy of the amnion), and by various 
abnormal presentations of the child. If, however, an examination 
conducted with due care at any time after the fifth month, and in the 
course of which the whole of the abdominal surface has been carefully 
explored, fails to detect the foetal pulse, this, of itself, is very strong 
evidence, either that pregnancy does not exist, or if it has existed, that 
the foetus is dead. 

It is generally believed to be possible to determine, by means of 
stethoscopic examination, the existence of a twin pregnancy by the 
following peculiarities : that, in twin pregnancies, the two hearts are 
heard beating at opposite points of the abdomen, and that they are 
frequently not synchronous in their action. If the latter point can 
be conclusively established by the simultaneous examination of two 
observers, the case is clear ; but in regard to the mere existence of 
pulsation at two opposite points of the abdomen, this cannot be ad- 
mitted as satisfactory proof. It has by some been asserted that the 
distinction is easy, and that, when we have pulsation at two points, in 
a single pregnancy, the sounds reach their greatest intensity midway 
between the two ; whereas, in a twin pregnancy, examination in the 
intermediate area gives a negative result. This, if true, would be a 
sure and easy test ; but we are perfectly certain it is not to be relied 
upon, although it may represent the general rule. Still taken along 
with the shape of the abdomen, and the results of careful palpation, 
pulsation at two points is an important symptom in the diagnosis 
of twins, which are generally placed to the right and left in the 
womb. 

Funic Souffle. — Dr. E. Kennedy has described another stethoscopic 
sound, which is synchronous with the foetal heart. " In some cases," 
says he, " w r here the uterus and the parietes of the abdomen were 
extremely thin, I have been able to distinguish the funis to the touch 
externally, and felt it rolling distinctly under my finger, and then, on 
applying the stethoscope, its pulsations have been discoverable, remark- 



IX.] UTERINE SOUFFLE. 171 

ably strong ; and on making pressure with the finger for a moment 
on that part of the funis which passed towards the umbilicus of the 
child, I have been able to render the pulsations less and less distinct, 
and even, on making the pressure sufficiently strong, to stop it alto- 
gether." This assertion of Dr. Kennedy's has been vigorously con- 
troverted in Germany ; but even admitting the description to be abso- 
lutely correct, the observation is one, as has been well observed by Dr. 
Tyler Smith, " which can hardly be of practical use, because when the 
abdominal and uterine walls are so thin as to permit us to feel the pul- 
sation of the funis through them, the other auscultatory signs of preg- 
nancy, and the evidence obtained by palpation, must already have set 
the question at rest; and except under such circumstances, it must be 
very difficult to discover the funicular souffle." 

Uterine Souffle. — The " bruit de souffle," " placental souffle," and 
Uterine Souffle, arc among the most familiar of the designations which 
have been applied to another and an important auscultatory sign, which 
was originally discovered, in 1823, by M. de Kergaradec, but for 
whom, also, the more important observation of M. Mayor would have 
been overlooked. The various names by which the souffle is described 
point pretty clearly to the well-known fact, that speculations as to its 
nature and its cause have given rise to various theories, which display 
the existence of very contradictory opinions. All agree that the sound 
is maternal, not foetal, as its rhythm corresponds to that of the mater- 
nal heart. The universal acceptation of the term " souffle" shows that, 
in regard to the nature of the sound, observers are at one. But, in so 
far as its seat and mode of production are concerned, great divergence 
of opinion has existed. 

The Uterine Souffle, as, for reasons to be stated presently, and fol- 
lowing Dubois, we prefer to call it, is distinguishable at an earlier 
period than the foetal pulsation. Dr. Kennedy, who has given much 
attention to this, as to the other signs of pregnancy, maintains that he 
has heard it as early as the tenth week ; but usually, it is not till the 
sixteenth week, or even later, — or, in other words, until the uterus is 
accessible to the stethoscope, — that it can be made out. These remarks 
apply to examination through the abdominal walls; for, if the metro- 
scope of M. Nauche be used, it is possible that it may be heard at a 
somewhat earlier period. An occasional characteristic of the sound is 
that it is not constant. It may be distinctly audible at one moment, 
and may disappear the next, to return again in a short time, — these 
changes taking place without any appreciable cause. In some cases, 
it is heard over the whole abdomen ; while, in others, it is confined 
within a limited boundary, usually in the region of the groin. Gen- 
erally it is heard, in advanced pregnancy, over the whole of the lower 
part of the uterus, but not over the fundus, nor in the lumbar region ; 
but, in the earlier months, it may be heard over the symphysis, or 
wherever the uterus is accessible to the stethoscope. In regard to tone 
and pitch, the varieties are endless, — presenting, in fact, from the soft 
whiff to the musical cooing or rasping sound, all the peculiarities of 
aneurismal or cardiac murmurs ; and what is not a little remarkable, 



172 SIGNS OF PREGNANCY. [CHAP. 

it varies in this respect, not only in different individuals, but in the 
same individual at different times. 

If the observations be made during a labor pain, a very striking 
effect is often found to be produced by the contraction of the uterine 
fibres, the sound becoming, in the first instance, louder, more sibilant, 
or even musical, and then, at the height of the pain, becoming lost — to 
return, as it passes off, in the inverted order of the tones, as the pres- 
sure on the vessels is relaxed. It seems to have no fixed relation to 
the site of the placenta, and it certainly gives no reliable evidence, as 
might, perhaps, have been expected, as to where the placenta is 
situated in the uterus. The uterine souffle as a sign of pregnancy, is, 
no doubt, extremely valuable, and is to be distinguished from any 
other arterial sound by the absence of impulse, and its persistence in 
every posture; but it must, on no account, be admitted as a certain 
sign. For, the attention which has of late years been given to the 
diagnosis of ovarian tumors has shown that one of the more constant 
signs of a pathological uterine tumor, and which goes far to distinguish 
it from a similar structure which has sprung from the ovary, is the ex- 
istence of a souffle, which has the closest possible resemblance to the 
souffle of the pregnant womb. 1 Under no circumstances is the uterine 
souffle to be held as proof of the life of the child. 

A certain number of observers were long of opinion that the sound 
which we are now considering was caused by pressure on the great 
arterial trunks which lie in the posterior part of the pelvis. This 
must at once be admitted as a possible cause of such a sound, seeing 
that pressure on vessels in any situation may produce a souffle. But 
that this is not the case in pregnancy, seems to be proved by the fact, 
that such a change of posture (the prone position, for example), as 
would remove the uterus for the time being from the neighborhood of 
the vessels, never has the slightest effect in arresting the souffle. The 
view which was entertained by M. Kergaradec himself in regard to 
the production of the sound, was that it was produced in the utero- 
placental vessels, and on this account he named it the " bruit placen- 
taire." That it is not so, is now universally admitted, and the idea 
was, indeed, completely refuted by the discovery that the sound is 
heard at so many various sites, and still more conclusively by the 
observations which have been made after delivery, and which have 
proved that not only may the sound be heard after the birth of the 
child, but even after the placenta has been expelled. 

The theory which owes its origin to Dubois is as follows. This 
distinguished accoucheur assumed that the blood, in passing from the 
uterine arteries to the uterine veins or sinuses, presented characters 
precisely analogous to those which constitute aneurismal varix, or which 
produce the souffle in erectile tissues. In all of these cases, as he 
observes, we have arterial branches discharging their blood directly 
into veins, the more rapid current joining a more sluggish one ; and 

1 Many believe this to be due merely to pressure on neighboring large vessels. 
Sometimes it is so ; but we are persuaded that the cause of the sound is generally in 
the uterine walls. 



IX.] UTERINE SOUFFLE. 173 

this, he adds, " is undoubtedly the cause of the murmur and the bruit 
de souffle which is so remarkable in aneurismal varix and erectile 
tissues/' His conclusion is that, very probably, the same causes within 
the uterine walls produce the same results. A theory somewhat similar 
to that of Dubois has been advanced by Corrigan, with the additional 
suggestion that the sounds are modified by pressure of the foetus against 
the uterine walls. De la Harpe believed that the sound was due simply 
to the multiplicity of currents of blood within the uterine walls : the 
sound from each vessel being, by itself, inaudible, but the aggregation 
of many giving rise to the familiar sound. Finally, there is the view 
of Scanzoni, who holds that the blood during pregnancy is in a chlo- 
rotic state, and that the sound is due mainly to causes which have 
their seat in the composition of the blood, and are accompanied by 
murmurs analogous to those with which we are familiar in the case of 
chlorotic women. The ingenious theory of Dubois may, no doubt, in 
some particulars, be inaccurate ; but the opinion now generally enter- 
tained of the cause of the bruit is — that it has its origin in the uterine 
walls, and neither in the vessels external to them, nor in the placenta 
within them, and that, therefore, the views of Dubois and Corrigan 
are, in all probability, very near the truth. 

As has already been observed, the movements of the foetus may 
occasionally be observed, by means of the stethoscope, at a very early 
period. This mode of investigation, which we owe to the younger 
Naegele, is one which is surrounded by so many difficulties and sources 
of fallacy that, important as it seems to be, it is never likely to be of 
any great practical worth. The possibility, however, which is un- 
doubted, of thus recognizing foetal movements at a time when the other 
evidence must be very inconclusive, is a point not to be lost sight of. 
Possibly this, as well as the other stethoscopic sounds, might be early 
recognized by the use of the Metroscope, a modification of the stetho- 
scope, which was devised by Nauche with the view of directly auscul- 
tating the uterus from the vagina, but which has fallen into disuse. 

The Signs of Pregnancy consist, then, of a few which are Certain, 
and of a considerable number which are Probable or Presumptive. 
The certain signs are : 

1. The Sounds produced by the Pulsations of the Foetal Heart. 

2. The Active Movements of the child, distinctly felt by a skilled 
person. 

3. The Passive Movements, in which consists the sign of Ballotte- 
ment. 

If any one of these signs is made out, the woman is incontestably 
pregnant. But, in regard to the negative evidence which is afforded 
by their absence, this can only be admitted as proof that the woman is 
not pregnant when the other signs are wanting: the absence of one is 
only sufficient to warrant a doubt. To the three certain signs given 
above, we might, perhaps, add a fourth, — the secondary areola of Mont- 
gomery ; but, as this is open to doubt, and is only to be observed in a 
limited number of cases, we include it among the probable signs. 



174 



SIGNS OF PREGNANCY. 



[CHAP. 



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perienced by mother about the 
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coucheur some weeks later. 

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18th week. 

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ment can be made out about the 
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served. 


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Fundus still below the level of 
the pelvic brim. 


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week, and is midway between 
pubes and umbilicus at end of 
16th. It is distinguished by pal- 
pation and percussion. 

Less depression of Umbilicus: 
hypogastric flattening disappears. 

Os reached with more difficulty, 
and is situated somewhat to the 
left. 


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little beneath the umbilicus at the 
20th, and a little above it at the 
24th week. 

Rounded central tumor in hy- 
pogaster, becoming gradually 
more apparent 

Umbilical depression almost 
effaced. 

Os and Cervix still higher. 


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slight deepening in color of the 
Areola. 


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Follicles projecting beyond the 
level of the skin. 

Morning sickness, and other 
digestive disturbances less. 

Certain effects of mechanical 
compression now often observed, 
such as varicose veins, and oedema 
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176 DURATION OF PREGNANCY. [CHAP. 

It is quite unnecessary that the latter should be again enumerated. 
Singly they are of no value; but, when a considerable number of them 
are simultaneously observed, in cases where pregnancy is expected, as 
in married women, the evidence thus afforded is tacitly admitted as 
complete. For such a diagnosis the medical attendant should not be 
held responsible; but if it turns out, after all, to be a mistake, he will 
find that, in accounting for the blunder, a large share of the blame will 
lie at his door. For a certain opinion, such as one would be warranted 
in giving upon oath in a court of justice, no combination of merely 
probable signs will suffice. In addition to these, however imposing 
their array, we must, in every case, have one at least of the certain 
signs, before we can, with.all confidence, assert that the woman bears a 
living child. 

If the child is dead, it is obvious that two out of the three signs are 
no longer available ; but, in these cases, there may still be ballottement, 
or there may be present signs which are held to indicate the death of 
the foetus, and which will be noticed in their proper place. The ques- 
tions may be put to us: Is pregnancy probable in this case? or, Can 
you say with perfect confidence that the woman is not pregnant? The 
reply to such questions must be given with the greatest caution, and 
will depend very much on the correct appreciation of the various 
probable signs, and the exact value which attaches to each, or to each 
group of such signs. In most cases of doubt, some period will be given 
as the probable or possible time from which, if existing, the pregnancy 
must date ; and it will be upon a careful analysis of the signs proper 
to such period of pregnancy as may thus be indicated, that our opinion 
will, in the end be formed. With a view of facilitating such an 
investigation, the preceding table has been drawn up, in which is given 
the average period at which the various signs are available. 



CHAPTEK X. 

DURATION OF PREGNANCY— SUPERFCETATION. 

DURATION OF PREGNANCY : IN COWS AND MARES : IN WOMEN — PROTRACTED PREG- 
NANCY : CASES OF — DIFFERENCE IN RATE OF DEVELOPMENT — MODE OF CALCU- 
LATING THE PROBABLE TIME OF DELIVERY : CALCULATION FROM LAST MEN- 
STRUATION TO BE CORRECTED BYPKRIOD OF QUICKENING — SUPERFCETATION : 
TO BE DISTINGUISHED FROM SUPERFECUNDATION — PROOFS OF THE LATTER — 
TWIN PREGNANCY IN RELATION TO THIS SUBJECT — CASES — CONCLUSIONS. 

The Duration of Pregnancy is a subject which, in so far as regards 
the human race, is enveloped in no little obscurity. Our chief diffi- 
culty arises from the fact, that it is only in a very small number of 
cases that the date of fertile coitus can be accurately ascertained ; and, 
further, in the majority of these, it is probable that the data are open 



X.] STATISTICS. 177 

to doubt.- For example, when an unmarried girl says she is pregnant 
from a single coitus, may we not suspect that she does so to palliate her 
fault, as she can no longer conceal her shame ; and the more closely, 
indeed, Ave investigate this class of cases, the more convinced do we 
become that many instances of so-called pregnancy from a single act 
should not be admitted in evidence. The proof, however, which is 
afforded by undoubted cases of this nature, and that which is derived 
from other sources, is sufficient to show that there is a considerable dif- 
ference in the duration of pregnancy, consistent with maturity of the 
foetus and a normal state of the pregnancy from first to last. 

In the Mammalia generally, one coitus, coinciding, as it does, with 
the period of rut, is generally followed by conception. This admits of 
observations of an exact kind in the case of many of our domestic ani- 
mals ; by means of which, indeed, much of, what is known in this do- 
main of physiology has been, in a great measure, established. In 1819, 
M. Tessier submitted to the Academie des Sciences at Paris the result 
of a series of investigations of this nature, which are of some interest 
as illustrating by the light of comparative physiology the question 
which we are now considering. The observations were, in fact, insti- 
tuted with the object of determining the possibility of protracted ges- 
tation in the human race. The following are the leading results : 

Of 140 Cows : 14 calved between the 241st and the 266th day. 

53 " " 269th " 280th " 

68 " " 280th " 200th " 

5 " " 290th " 308th " 

The extreme difference between the births, in an animal in which ges- 
tation is only a little more protracted than in women, being thus 67 
days. An extended series of observations of a similar nature, and 
yielding similar results, was conducted by the late Lord Spencer : 



Of 102 Mares 


3 foah 


d on the 




311th day. 




1 


" 


u 




314th " 




1 


" 


n 




325th " 




1 


(< 


a 




326th " 




2 


(t 


u 




330th « 




47 


si 


between 


the 


340th and the 350th day 




25 


n 


u 


« 


356th " 360th " 




21 


a 


a 


t 


360th " 377th " 




1 


a 


on the 




394th day. 



The extremes in this case embracing a period of no less than 83 days. 
Of course, as regards the cases in which the birth took place much 
earlier than the ordinary period, it may be said that they were examples 
of premature delivery ; but even if, by striking them off, we remove this 
possible fallacy, there still remains a sufficiency of facts to prove that, 
in those animals, there is considerable latitude as to the exact day at 
which labor may be anticipated. And, if this be the case in animals, 
where sexual excitement is in abeyance during the whole period of 
gestation, is it not even more likely to obtain in the case of women, in 
whom sexual excitement persists, and who are exposed to moral and 
social influences, and to diseases, one and all of which may act as dis- 
turbing influences, and thus cause irregularities in the period of deliv- 

12 



38th ' 


' —260 to 2ii6 


30th < 


< —267 to 273 


40th " —274 to 280 


41st < 


' —281 to 287 


42d « 


' —288 to 294 


43d « 


' —295 to 301 



178 DURATION OF PREGNANCY. [CHAP. 

ery ? And, in point of fact, this has been shown to be the case by 
numerous examples which have been carefully noted by experienced 
observers. The usual method of determining the approximate duration 
of pregnancy, it being impossible to fix the date of conception, is to 
make the calculation from the last day on which the menstrual dis- 
charge was observed. It was upon this principle, and selecting those 
cases only in which this starting-point could be exactly determined, 
that Dr. Merriman conducted his investigations, with the results which 
are quoted in almost every work on obstetrics. Of the 150 mature 
births observed by him — 

5 were delivered in the 37th week — 255 to 259 davs. 

16 " " 

2i " » 

46 " " 

28 " " 

18 " 

11 " « 

5 " " 44th, the latest being the 306th day. 

In this most interesting and reliable table a difference is shown 
between the extremes of 51 days. The following table, of no less than 
500 cases, by Dr. James Reid, is of no less interest, and is calculated 
like that of Merriman from the last day of menstruation. 

Of the 500 cases — 

23 were delivered in the 37th week — 255 to 259 days. 

48 " " 

81 " " 

131 " " 

112 " 

63 " " 

28 " " 



the difference between the extremes being in this case no less than 60 
days. 

The results yielded by these two tables prove that, calculating in 
this manner from the last day of the last menstruation, considerable 
variations in the duration of pregnancy seem to occur. But such 
seeming variations must be viewed with caution. Our calculation is not 
here, as in cows and mares, from the very day and hour of coition, 
but is made in full knowledge of the fact that conception may have 
occurred on any one day of a period extending over more than three 
weeks. Such conclusions as may be admitted, upon an analysis of the 
cases of single coitus in the human species which are on record, tend 
to show pretty clearly that, although the range is less than in the 
lower animals, there is an undoubted variation within certain limits. 
Dr. Reid, in the series of papers from which the above table was taken, 
gives an analysis of 43 cases of single coitus which he had collected ; 
but as we entertain grave doubts of the accuracy of such tables, for 
reasons already stated, we refrain from quoting it in extenso. Accord- 
ing to it, delivery took place in from 260 to 300 days, a range of no 



38th ' 


' —260 to 266 


39th « 


< —267 to 273 


40th ' 


' —274 to 280 


41st " —281 to 287 


42d ' 


« —288 to 294 


43d " -295 to 301 


44th « 


' —302 to 308 


45 th ' 


< —309 to 315 



X.] IRREGULAR CASES. 179 

less than 40 days, and the average duration of gestation is shown to be 
about 275 days. 

The facts above cited seem to show that the question of the duration 
of pregnancy is one which is of the highest importance not only in an 
obstetrical, but in a legal sense; and it is indeed upon the facts established 
by scientific and obstetrical research, and the opinions which are 
founded upon them, that the laws bearing upon the subject have been 
framed, and are interpreted in courts of law. One of the most inter- 
esting cases of this kind on record is the well-known Gardner peerage 
case, of which the following is a brief outline: 

" Lord Gardner parted from his wife on board of his ship on the 30th of January, 
1802, and, having proceeded to the West Indies, did not see her again until the 11th 
of July following. Lady Gardner had been living in open adulterous intercourse 
with a Mr. Jadis, and on that account his lordship obtained a divorce after his re- 
turn, and subsequently contracted a second marriage. The case came before the 
House of Lords in 1825, when Allan Legge Gardner, the son of Lord Gardner, by 
his second wife, petitioned to have his name inscribed as a peer on the Parliament 
Boll. Another claimant, however, appeared in the person of Henry Fenton Jadis 
or Gardner, who alleged that he was the son of Lord Gardner, by his first, and sub- 
sequently divorced wife. He was proved to have been born on the 8th of Decem- 
ber, 1802, and the question in view of the above facts simply was (as the. possibility 
of the pregnancy dating from July was not put forward) whether a child born 311 
days from possible intercourse, could have been the child of the -deceased Lord 
Gardner. The medical evidence, as, unfortunately, it too often is in such cases, was 
very contradictory, but is particularly interesting as bringing out the opinions of 
the greatest obstetrical authorities of the day. Sir C. Clarke, Dr. Gooch, and Dr. 
Davis, stated their belief that forty weeks (280 days) is never exceeded, while on 
the other hand, Drs. Blundell, Conquest, and Granville asserted that the period 
was in some cases undoubtedly exceeded, and to such an extent that they were war- 
ranted in admitting the possibility of the claimant, Henry Fenton Jadis, having 
been a ten and a half months' child. Their lordships found that the elder claim- 
ant was illegitimate, arid that, consequently, the son of the second marriage was 
Lord Gardner. It must be admitted, however, that the moral evidence in this case 
had probably more weight than the medical." 

Since this decision, the attention of the profession has been much 
more carefully directed to this subject, and probably no one at the 
present day would venture to assert that 280 days is the ultimum tempus 
pariendi which some legal authorities suppose it to be. Were we able 
to date from the moment of conception, which under no circumstances 
is possible to us, Ave could soon collect sufficient data to guide us in 
future. But we must not forget that, even in those cases in which the 
calculation is made from a single coitus, the time of insemination does 
not necessarily mark the time of fecundation, and there is good reason 
to believe, from what has been observed in the lower animals, that 
some days may elapse before the fertilizing principle encounters the 
ovum. [This opinion is sustained by the fact, that spermatozoids 
have been seen in motion on the surface of the ovary, eight days after 
intercourse (Flint, Jr.) Dr. S. R. Percy discovered them alive in 
the mucus issuing from the os uteri eight days and a half after the 
last coitus. — P.] Then, again, if we date from menstruation, Ave must 
admit the possibility of irregular menstruation prior to impregnation, 
in which case conception may occur six weeks or more after the last 
menstruation. And if we admit this, as Ave tacitly do in cases of mar- 
ried Avomen Avho carry the child longer than usual, Ave are bound in 



180 DURATION OF PREGNANCY. [CHAP. 

common fairness to allow the same argument to those who wish to 
prove the possibility of protracted pregnancy. The following instance, 
from the writer's case-book, will serve to illustrate this : 

u Mrs. P., who before had borne one child, ceased to menstruate on the 11th of 
September. On the 23d of December, she had slight haemorrhage and other symp- 
toms of threatened abortion. Nothing solid came away, and she was confined 
strictly to bed until all the symptoms had disappeared. Previous to this she had 
had morning sickness. In the course of the month of February, she felt motion, 
but did not note the date. Development went on as usual, and she enjoyed excellent 
health. 

" On the 17th of July I visited her, being somewhat astonished at the duration of 
the pregnancy. On examination I felt the outline and feet of the child quite dis- 
tinctly, the latter moving vigorously in the right hypochondriac region, where the 
movements had subjected the mother to much annoyance The os uteri was patent, 
so as to admit the point of the finger, and was quite cushiony and soft. The ^ervix 
was short, but quite perceptible. The presenting part could not be reached by the 
finger. On the 22d of July, 314 days from the last menstruation, a male child was 
born of average size and quite healthy." 

In this case menstruation was habitually irregular, and there was 
often an interval of six weeks between the periods. If we assume 
therefore that impregnation occurred immediately before a menstrual 
period, after an interval of six weeks (42 days), this would make the 
duration of pregnancy exactly 273 days. 

The following case is of a somewhat similar nature, but is further 
interesting as affording an illustration of what we believe to be in 
many cases an essential element in determining the probable duration 
of pregnancy. The sensation of quickening is generally, as has been 
observed, perceived by the mother a little before the middle of preg- 
nancy, and should always be accurately noted, if possible. Were this 
done in every case, it would serve to correct errors which may arise 
from calculations based exclusively on the last menstruation. Had it 
been done in the following instance, some trouble and anxiety might 
have been saved ; and the same remark might possibly apply with equal 
force to many of the so-called examples of protracted gestation : 

Mrs. M., who had previously borne eight children, ceased to menstruate on the 
13th of September. For some months after this she suffered much from spasmodic 
asthma, which seemed to be associated with the pregnancy, of the existence of which 
she was for some time doubtful. The movements were said to be less vigorous on 
this than they had been on former occasions, but in all other respects she progressed 
very favorably, the asthma becoming much less in proportion to the advance made 
in the pregnancy. The calculated time having long passed, and a more careful 
questioning having been adopted, it was found that quickening dated/rom thefirst 
week in March at soonest. Only one menstruation had occurred since her former 
pregnancy. 

July 24th. — On examination, the os is found to be patent. A few pains have 
occurred. Head easily reached and presenting. 

July 31st. — Child born at 5 a.m., 322 days from the last menstruation. 

If impregnation had not occurred in this case, we may suppose it 
possible, if not probable, that the second menstrual period after the 
former confinement would have taken place between six and seven 
weeks after the first, and that impregnation had occurred immediately 
before it — say on the 24th of October, or 280 days before birth. 

The last case which we shall cite in illustration of this subject is one 
of special interest, inasmuch as it is calculated from a single coitus 



X.] PROBABLE MAXIMUM. 181 

under circumstances which leave no room for doubt as to the facts, and 
in which the pregnancy was unusually prolonged: 

The subject of the case in question, Mrs. R., had previously had seven children, 
one having been a transverse presentation, and several having been delivered with 
the forceps. Her general health being indifferent, she dreaded greatly another 
pregnancy, and on that account absented herself from her husband's bed. In the 
month of March the latter went on a visit to the country, where Mrs. E. visited 
him for a single night, circumstances having arisen which obliged her to go to the 
Continent, where she remained for two months. The date of this visit was the 2d 
of April, and before her return home she was convinced by previous experience 
that she was pregnant. The date of the last menstruation was a little uncertain, 
but was about the 27th of March. To the astonishment of every one who knew the 
circumstances, the pregnancy continued far beyond the ordinary limits, until, on 
the 22d of January, she was delivered of a very large male child weighing 12 lb. 3 
oz , 295 days from what we believe to have been beyond all doubt a solitary coitus. 
An interesting point in the case was the great size of the child, indicating, as it 
might be, that it had been retained within the womb beyond the ordinary period of 
maturity. 

Many writers, among them Scanzoni, maintain, and some observa- 
tions seem to confirm their view, that the rate of intra-uterine develop- 
ment is not always the same; and that children born mature at an 
earlier period than usual are to be described as exceptional (Graviditas 
Prceeox), while the contrary class of cases are those in which, develop- 
ment being slow, maturity is not reached until a period considerably, 
beyond the average (Graviditas Serotina). 

The facts just stated furnish a general confirmation of the observa- 
tions of those whose conclusions are embodied in the tables which we 
have given. The maximum, according to Peid, is 393 days, as deduced 
from his cases of single coitus; our own case above quoted is 295 ; and 
Merriman's maximum of 306 days from the last menstruation will, if 
calculated from the probable time of conception, give about the same 
result. In Scottish Law, and in the French Code, the period of 300 
days is fixed as the utmost possible limit, and in Prussia 301, so that 
in these countries the child of a woman who is delivered 302 days after 
the death or proved absence of her husband is declared illegitimate. 
Difficult as it is, and always must be, to fix precisely the limit, we are 
inclined to think that these laws are just; for while it is the object of 
the law, from one point of view, to protect the innocent offspring from 
the brand of illegitimacy, if it be possible to do so, it is in like manner 
the duty of those who administer the law, not rashly to confer the posi- 
tion and privileges of legitimacy upon the fruit of adulterous intercourse. 
In English Law, no period or limit is fixed, and cases, when they arise, 
fall to be decided in the light of the medical evidence of experts, and 
of the moral and collateral aspects of the case. In America, a more 
liberal view is taken, to judge from some legal decisions which are 
quoted by Taylor, where paternity was held to be proved in two cases, 
the duration of the pregnancy from coition being shown in one to be 
313, and in the other 317 days. It is possible that the American 
views on this subject may have received their color from the extreme 
views entertained by one of the most eminent obstetricians in that coun- 
try, Dr. Meigs, of Philadelphia, who has expressed a belief that gesta- 
tion might continue for a year, or even more. 



182 DURATION OF PREGNANCY. [CHAP. 

With reference to what has been said as to the probability of 300 
days being a liberal interpretation of a law of nature, it must not be 
forgotten that some very able obstetricians in this country have ex- 
pressed a contrary opinion. The names of Simpson and Murphy are 
a sufficient guarantee that the cases cited by them, on which they found 
their opinion that pregnancy may be prolonged considerably beyond 
the period named above, are free from the suspicion of careless investi- 
gation ; but, on the whole evidence before us, we conclude that the 
extreme cases must be disallowed, as the sources of fallacy are too 
numerous to warrant us, without clear evidence, to sanction the exten- 
sion of the possible limit. 1 

Speaking in general terms, pregnancy may be stated as lasting, under 
ordinary circumstances, for nine calendar months, — from 273 to 276 
days, according to the length of the months which intervene. But, as 
we are ignorant of the date of conception, and can only make the above 
calculation under very exceptional circumstances, some other mode has 
to be adopted in practice. It is a matter of some importance to the 
practitioner, and one on which his comfort in no small measure depends, 
to be able to forecast his obstetrical engagements ; and this subject is, 
on that account, to him one of special interest. A long series of careful 
examinations, conducted by independent observers, seems clearly to 
show that the period of impregnation is usually about a week after the 
cessation of a menstrual period. A ready method of reckoning, which 
is founded on this belief, is recommended by many German authors, 
and is very generally practiced by nurses in this country. It consists 
in taking the date of the last menstruation, reckoning three months 
back, and adding seven days. For example, a woman has ceased to 
menstruate on the 8th of June ; three months back (or nine months 
forwards), gives the 8th of March; to this add seven days = 15th of 
March, which will be found, in a large number of cases, to be within a 
few days of the actual time of delivery. 

For greater exactness, as well as for the purposes of general scientific 
accuracy, it is better to make the calculation in such a manner as may 

1 Some reliable information, in regard to this subject, may, as we believe, be 
derived from the observation of pregnancy in Jewish women. The author is 
mainly indebted to a very able physician and accoucheur of that persuasion for the 
following information. Among Jews the sexes are separate during menstruation, 
and for seven clear days thereafter. The shortest period allowed for menstruation 
is rive days, even should it last only for an hour or two, so that the minimum period 
of separation every month is twelve days; and, in anything approaching menorrha- 
gia, of course much longer. This law is observed by the vast bulk of the Jewish 
women : the exceptions are very few. After the period of separation, whatever that 
may be. the woman, besides an ordinary bath for cleansing purposes, must take what 
is called the "bath of purification." She simply dips in this, but does not wash. 
This gives a fixed day, from which a Jewish woman reckons, as she knows the 
day she went to the bath, and calculates accordingly. Any one who may have an 
opportunity of making observations in this direction, will find, 1st, that Jewish 
women calculate more accurately as to the duration of pregnancy ; 2d, that, ac- 
cording to their experience, the duration of pregnancy seems to be rather less 
than is usually supposed; and 3d (although this has less to do with the subject 
more immediately under consideration), that, as has been observed by a late writer 
in Germany, this frequent and protracted abstention from sexual intercourse may 
be admitted as a possible cause of the undoubted vitality of the Jewish race. 



X.] 



METHOD OF CALCULATING. 



183 



enable us to compare one case with another, and at the same time 
reduce possible error to a minimum. This is done by calculating in 
each case 280 days, or ten lunar months, from the last menstruation, 
which is equivalent (by deducting seven days) to nine calendar months 
from the assumed date of conception. This calculation, simple as it is, 
implies a certain amount of trouble, to reduce which various tables 
have been constructed. Such tables, however, as are given by Naegele, 
or by Murphy, after Dr. Ryan, are too elaborate to be of any real 
practical every-day use, and to read them requires almost as much 
trouble as to make the original calculation in each case. A much 
more useful and satisfactory one is the following, which is very easily 
read, and from which the calculation necessary may be made in a few 
seconds. 

Around the circle are arranged, in their order, the months in the 
year, with the number of days in each. The number placed below 
each month gives the number of days which must be added to the 



Fig. 90. 




To calculate the duration of pregnancy. (After Schultze.) 



nine preceding months in order to make up 280 days. If the month 
of February in a leap year is included in a pregnancy, it is estimated 
by the number in brackets. 

We reckon, in order to find the next 280 days from the starting- 
point (the last day of menstruation), nine months forwards (or, more 
simply, three months backwards), and add to the date thus reached the 
number standing below the name of that month. 

Example 1. — Last menstruation, the 10th of February, count three 
months back = November 10th -f 7 — November 17th (in leap year, 
November 10th + 6 = November 16th). 

Example 2. — Last menstruation, 24th March, = 29th December, == 
280 days. 



184 DURATION OF PREGNANCY. [CHAP. 

Example 3. — Last menstruation, 30th September, 1863, = July 7th, 
1864, = 280 days. 

Example 4. — Last menstruation, 31st May, 1863, = March 7th, 
1864, = 280 days. 

The last example shows how to proceed when, at the end of the 
month, there may be a doubt as to the calculation. 

The 31st of February is equivalent to the 3d of March, which + 4 
== 280 days. 

An equally simple calculation may be made when, in medico-legal 
investigations, we want to calculate backwards from the day of birth 
to the probable cessation of the menses 280 days previously. In this 
case, we count three months forwards, and subtract the number stand- 
ing under the birth-month. 

Example 1. — Birth, 31st October, = Menses, January 31st, — 7 — 
January 24th, or 280 days. 

Example 2.— Birth, 20th April, = Menses, July 20th, — 6 = 
July 14th, = 280 days. 

Impregnation may take place at any time during an intermenstrual 
period. It is believed, however, that the time at which it most fre- 
quently occurs is about seven days after the last menstruation, and that 
the epoch next in point of frequency is immediately before the succeed- 
ing menstrual period. It will be observed that we have thus a range 
of three weeks within which impregnation may occur, even when the 
menstruation is quite regular, and this fact serves to explain, as we 
believe, the great majority of those cases in which a woman appears to 
carry the child for three weeks beyond the calculated time. Indeed, 
when a woman goes one week beyond the 280 days, we have come to 
look upon it in practice as by no means unlikely that she will carry 
her child for fourteen days more. 1 

The errors which arise from this method of calculation are of such 
frequent occurrence, that we find it of great advantage, when practica- 
ble, to correct this observation by another, as has already been inci- 
dentally observed — to wit, the quickening. In regard to this sign of 
pregnancy, there certainly exists much self-deception on the part of 
women, and, moreover, it is, as Dr. Reid remarks, seldom that they 
can tell us the exact day on which they first feel it. The vulgar be- 
lief is that the period when it is first felt indicates the middle of preg- 
nancy, or four and a half calendar months ; but the opinion of the most 
experienced accoucheurs is that it is, as a rule, perceived about the end 
of the fourth calendar month, or about a fortnight before the middle of 
the term. About the seventeenth or eighteenth week, therefore, may 
be set down as the most usual period. Its value, as a sign of the dura- 
tion of pregnancy is unfortunately much diminished by the long period 
during which it may for the first time be experienced ; but, still, its 
value is very considerable in this way, that, if we have a case to deal 
with of apparently protracted pregnancy, it is unlikely that any con- 

1 This term of 280 days is of special interest from another point of view, as 
marking the tenth menstrual period from conception. (See " Causes of Labor," 
Chapter XV.) 



X.] SUPERF(ETATION. 185 

siderable error should arise both from the quickening and the menstru- 
ation in the same case. By this precaution, therefore, the risk of mis- 
calculation is certainly diminished. 

When, as is usual in midwifery practice, the services of the accoucheur 
are engaged beforehand, he should, for his own satisfaction, uniformly 
ascertain the date of the last menstrual flow, and not be content with 
the scanty information usually given that she expects her confinement 
" early in the year," or " about the middle of June/' Having ascer- 
tained the fact and noted it, he must then inquire as to the quickening, 
and if the information is sufficiently clear, he must note that also. Or, 
if the woman has not yet arrived at the period of her pregnancy when 
this sign manifests itself, she must be requested to make an accurate 
note of her quickening, with a view to the subsequent information of 
her medical attendant. With the facts thus disclosed before him, he 
may then, by an application of the principles already laid down, make 
a calculation which, with ordinary care and discrimination, will rarely 
mislead him. 

Superfoetation. — It is generally, although not universally, admitted 
by those who have devoted most attention to the subject, that it is quite 
possible for one impregnation to succeed another, in the same pregnancy, 
within a certain limited period, and it is all but proved that, in this 
manner, twin pregnancies do occasionally occur. This is, however, not 
superfoetation, but merely superfecundation; the essential distinction 
between the two being, according to Scanzoni, that the former must 
be held as occurring after the period at which the decidua vera and 
decidua reflexa come into close contact. Under the head of Superfe- 
cundation we must class cases, of which many are on record, of women 
who have borne twins of different colors, after having had connection 
successively with a negro and a white man. Scanzoni, who rejects the 
idea even of superfecundation, explains such cases on the principle 
that children sometimes resemble the father, and, at other times, the 
mother, both in features and complexion. In twin pregnancies, one 
child occasionally resembles the father, while the other resembles the 
mother. It seems, on this ground, quite possible to him that all that 
is necessary for the production of a black child and a white one is 
cohabitation between a black man and a white woman ; or, what is 
vastly more common, a white man and a black woman. It is quite 
certain that the orifice of the Fallopian tube remains, during the early 
months of pregnancy, quite patent; and that the mucous plug in the 
os internum does not hermetically close the cavity. In fact, the ana- 
tomical conditions are such that, but for the fact that the maturation 
of ova does not usually go on during pregnancy, the difficulty would 
rather be to discover why superfecundation was not more common. 
Physiologically, the real impediment lies in this fact, that the highest 
function of the ovary remains in abeyance from the period of concep- 
tion till some time after delivery. If, therefore, ovulation should ex- 
ceptionally go on — which Dr. Matthews Duncan supposes may be 
indicated by exceptional instances of menstruation during pregnancy — 
there is no difficulty in admitting the possibility of superfecundation 
under such circumstances. 



186 SUPERF(ETATION. [CHAP. 

It is otherwise with Superfoetation, the possibility of which has been 
vigorously opposed by Wagner, who termed it a physiological impossi- 
bility ; and by most of the modern English writers, among whom we 
may mention Drs. Ramsbotham and Churchill. The idea implied is, 
that a woman who already bears within her womb a living foetus may, 
at a stage of pregnancy more or less advanced, again conceive, and thus 
carry simultaneously the fruit of two conceptions, between which there 
must be a considerable interval. A careful analysis of the so-called 
cases of superfoetation, and especially of the older cases, shows conclu- 
sively that, in most of them, the phenomena were quite consistent with 
the idea of ordinary twin pregnancy. Numerous cases are on record 
where, abortion having taken place, one twin has then been expelled, 
while the other has gone to the full time. Others, again, occasionally 
occur in which a mature child and a small withered one are born 
together. But it needs no argument to show that, although instances 
such as these may excite surprise among the ignorant, they are quite 
in keeping with what is known of the physiology of twin pregnancy. 
A number of the recorded cases are so obviously to be accounted for 
in this way, that we are almost tempted to refer, without any further 
investigation, all such to the same category. But an impartial con- 
sideration of the numerous examples which have been advanced in 
support of superfoetation will not permit such a summary treatment of 
the subject. 

Among the cases frequently quoted, is one which was published in 
the Transactions of the College of Physicians. 

" Mrs. T., an Italian lady, who was married to an Englishman, was delivered of 
a male child at Palermo, on the 12th of November, 1807 ; and on the 2d of February, 
1808, she was delivered of a second male child." Both children were said to huve 
been born perfect, but a careful analysis of the whole facts as disclosed, seems to 
show that the case in all probability comes under the class of twin pregnancies. 
Certain doubtful circumstances regarding the first infant, coupled with the fact of 
its early death, seem to point to the conclusion that it was born immature. 

Dr. Mobus of Dieburg reports a similar case, the narrative of and 
remarks upon which we take from Taylor's well-known work on 
Medical Jurisprudence. 

" A healthy married woman, about thirty-five years of age, was safely delivered 
of a girl on the 16th of October, 1833. The child is described as having been well 
formed, and having borne about it all the signs of maturity. This woman, it is to 
be observed, had previously had several children in a regular manner. Soon after 
her delivery, and the expulsion of the placenta, she felt, on this occasion, something 
still moving within her. On examination, the mouth of the uterus was found com- 
pletely contracted, and the organ itself so drawn up as to render it difficult to be 
reached; but the motions of a second child were still plainly distinguishable 
through the parietes of the distended abdomen. Her delivery was not followed by 
the appearance of discharge (lochia) or by the secretion of milk. The breasts re- 
mained flaccid, and there was no fever. On the 18th of November, thirty-three 
days after her first confinement, this woman, while alone and unassisted, was sud- 
denly delivered of another girl, which, according to Dr. Mobus, was healthy, and 
bore no sign of over -maturity about it. The reporter alleged that this case most 
unequivocally establishes the doctrine of superfoetation. The two births took place 
at an interval of thirty-three days, and the two children were, it is stated, when 
born, equally well-formed and mature ; but Dr. Mobus did not see the second child 
until twenty-four hours after birth. This may, however, have been a twin case, in 
which one child was born before the other. Dr. Mobus considers that the first child 



X.] ALLEGED EXAMPLES. 187 

was born at the usual period of gestation, it being described as mature; and that 
the other, thirtj'-three days after that period, having been, in his view, conceived 
so many days later than the first child. If, however, we imagine, that in this, as 
it often happens in twin case*, one twin was more developed than the other, and 
that the more developed was the first expelled ; or that it is not always easy to com- 
pare the degree of development in two children, when one is born before the other, 
and the two are not seen together, we shall have an explanation of the facts, with- 
out resorting to the hypothesis of a second conception after so long an interval. 
As to the signs of over-maturity alluded to, they are not met with. If we are to 
believe authentic reports, a child born at the thirty-ninth week cannot be distin- 
guished from one born at the forty-third or forty-fourth week, and children born 
at the full period vary much in size and weight. A longer time may be required 
to bring children to maturity in some women than in others; and in a woman with 
twins, it is well known that two children may arrive at the same degree of maturity 
within different periods — one requiring perhaps several weeks longer than the other 
for its full development." 

In a most interesting paper by Dr. Bonnar of Cupar-Fife, 1 a number 
of cases are given in which children, born in wedlock, succeeded each 
other with very unusual rapidity. The question of superfcetation is 
here looked upon from a different point of view, in reference more 
particularly to the period after parturition, at which the female pro- 
creative organs are again capable of exercising their functions. Dr. 
Bonnar gives three cases, all occurring in families of rank and posi- 
tion ; but we do not think it necessary to repeat the names, as some of 
the parties are still alive. In these cases, there intervened between the 
two deliveries 182, 174, and 127 days, and all the children were suffi- 
ciently developed to be reared, and, without exception, to reach ma- 
turity. How are we to explain these facts? We know that impreg- 
nation may occur within a very short period of delivery, long before 
the mucous membrane has gone through the process described by M. 
Robin, and been restored to its normal state. But, in the case last 
mentioned, this would only give about four calendar months from an 
impregnation assumed to date from six days after the last delivery, an 
age at which it would not be possible to rear the child, even upon the 
assumption of its being a case of so-called graviditas prwcox. If we 
reject this theory, and yet admit the facts which we believe to be be- 
yond question, there is only one other way of accounting for them, and 
that is to admit the possibility of superfcetation. 

Now, in regard to much of what has been urged in evidence against 
the possibility of superfcetation, it must be admitted that it is either 
irrelevant or inconclusive. Many, even of those who admit the prob- 
ability, within certain limits, of superfecundation, assume that a new 
conception is impossible — say in the second or third month — on account 
of mechanical impediments which exist so soon as the decidua is formed. 
We know, of course, that the complete development of the decidua 
reflexa is a barrier to the formation of another embryo within the 
pouch thus constituted, or, in other words, of an ordinary twin preg- 
nancy; but the researches of Coste most conclusively show, as has 
already been mentioned, that neither the Fallopian tubes nor the 
cavity of the cervix are closed so as to prevent communication between 
the vagina and the ovary. Or, to speak more plainly, there is no me- 

1 Edinburgh Medical Journal. January, 1865. 



188 SUPERFOETATION. [CHAP. 

chanical, nor, if the function of the ovary be not arrested, is there any 
physiological impossibility that a new ovum might be fertilized, at any 
period prior to that at which the decidua vera and the decidua reflexa 
come into contact, and be developed in a special decidual sac. But 
some of the last cited, if they are to be taken as cases of superfoetation, 
would seem to point to a new impregnation at a period later than that 
at which the two decidual layers come into contact ; a difficulty which 
is ingeniously got rid of by Dr. Matthews Duncan, who says, " if we 
suppose, in an instance of this kind, that the first child is born prema- 
turely, but within the limits of viability, we thus gain two months; 
and, if impregnation may take place between two and three months 
after conception, we have thus four or five months of interval accounted 
for between the births of successive viable infants." 

It is admitted on all hands that superfoetation may take place in cases 
of extra-uterine pregnancy. This, taken in connection with the facts 
hitherto ascertained with reference to menstruation during pregnancy, 
seems to indicate pretty clearly that the function of the ovaries is not 
necessarily interfered with in the course of gestation ; but, at the same 
time, cases of this nature must be considered as standing by themselves 
and not affecting directly the ordinary question of superfoetation. 

[It cannot be said that superfoetation is generally admitted as possi- 
ble after an extra-uterine conception. Women have repeatedly con- 
ceived while carrying a child, developed outside of the uterus, but we 
are aware of no facts which prove that a uterine impregnation is pos- 
sible, between the time that the misplaced conception occurs, and the 
complete restoration of the woman from the pseudo-puerperal con- 
dition, which follows the death of the child and the false labor, which 
occur at or near term in extra-uterine pregnancy. 

The history of extra-uterine pregnancy, contrary to the opinions ex- 
pressed by the author, appears to show that the function of the ovaries 
is interfered with during the course of gestation. It is only after the 
completion of this, and the restoration of the woman to the non-puer- 
peral condition, that she can conceive while carrying an extra-uterine 
child.— P.] 

An example of this is reported by Montgomery, in which, while the 
product of an extra-uterine gestation remained encysted within the 
abdomen, the woman bore three children, one of whom lived. A simi- 
lar case has been recorded by Dr. Steigertahl ; and another still more 
interesting by M. diet, of Lyons, in which a woman died suddenly, 
and, upon dissection, an extra-uterine foetus of five months was found 
in the abdomen, while a foetus of three months occupied the uterus. 

In another group of cases, of which many are on record, a second 
impregnation takes place, and development goes on within the un- 
occupied cavity of a double uterus. Of these, few present features of 
greater interest than one which was brought under the notice of the 
author by Dr. J. Harris Ross, of Brighton. It was embodied by him 
in his graduation thesis at the University of Glasgow in 1871, and 
was subsequently published in the Lancet. The following is Dr. Ross's 
report : 



X.] 



IMPREGNATION IN DOUBLE UTERUS. 189 



"Mrs. C , the subject of these remarks, is a woman aged thirty-three. She 

has been married fourteen years ; and, previous to the circumstance [ am about to 
relate, had been delivered of six children. With the last three I was the medical 
attendant; but had never before had the opportunity of examining the uterus, as 
the child on each occasion was quite at the outlet of the vagina when I arrived at 
her house. With the exception of once (when she was prematurely delivered of a 
seven months' child) the labors were all natural, and she always made a good 
recovery. 

"She sent for me in May, 1870, as she had considerable haemorrhage. She told 
me that she was pregnant, and that she had not menstruated since the previous 
February. On examination, I found the os uteri very flaccid and partially open, 
and another opening close to the left of it, which I supposed to be an excavated 
ulcer, and the cause of the haemorrhage. As she objected to the use of the spec- 
ulum. I ordered her to keep the recumbent posture, and to use an astringent injec- 
tion, which 1 sent her, together with some tonic medicine In a few days thehsemor- 
rhage ceased, and she got about her household duties until July 16th. 

" On the morning of that day she sent for me in a great hurry. 1 found her with 
strong labor pains; and on making an examination, I found a bag of membranes 
protruding from the uterus, which ruptured during my examination. After this 
the pains left her. I saw her several times in the course of the day, but the pains 
did not return until about nine o'clock in the evening, when they were of a very 
feeble character. On examination at this time I found another bag of membranes 
protruding, which I ruptured, as I thought it might stimulate the uterus to con- 
tract. A head then presented, and, after some time, the pains being very feeble, a 
foetus was expelled. On again examining, a leg presented, and after awhile I de- 
livered her of a second* i'oet us, and then of a double placenta — that is, one with two 
cords. The children were, I should judge, of nearer six than five months' growth. 
After I had removed the placenta, the patient exclaimed^. ' I am sure there is 
another, Mr. Ross,' — meaning another child. As the uterus felt rather bulky, I 
introduced my hand into the vagina, and my finger into the uterus, to make sure, 
but found the cavity quite empty. At this time the second opening in the uterus 
was plainly to be felt. The whole course of this labor was very different from her 
other ones ; the pains were very feeble, and the labor unduly long : this I attributed 
to her having twins. 

"About a week afterwards, the patient again declared that she had another 
child in the womb; but I pooh-poohed it, as I had madesuch a careful examination 
after delivery, that I felt certain that I could not have left one behind. She, however, 
persisted in her statement. One day I went to see her, and my hand being very 
cold, I placed it upon her abdomen, when I plainly felt the movements of a child, 
and on applying my stethoscope the foetal heart was quite audible. On exam- 
ination per vaginam, the two openings could distinctly be felt, when it at once 
dawned upon me that I had got a case of double uterus, with both sides impreg- 
nated at the same time. On introducing a sound into the apertures, there was no 
doubt they both opened into a cavity or cavities, but, as she was still pregnant, I 
did not then push the matter further. When laid flat upon her back the tumor 
in the abdomen was decidedly more to the right than the left side. As there was 
now no doubt about her being pregnant, 1 told her to send for me direct^ she was 
in labor. 

" She went on well until the morning of October 31st, when she sent for me at 
6 a.m. On my arrival, I found the head on the perineum, with the membranes 
protruding. I ruptured them, and delivered her of a female child of full growth 
in about a quarter of an hour afterwards. On examining the uterus (after removal 
of the placenta) I could get my thumb into one opening, and, by a little manipula- 
tion, my finger into the other, and could distinctly feel a septum between them. 
She slated that she had menstruated three times since her miscarriage of twins in 
July. Both mother and child made a good recovery." 

The conclusions, then, with reference to this subject, at which we 
think we are justified in arriving are, — 1st, That in regard to Super- 
fecundation, this is a phenomenon the existence of which there is no 
reason to doubt; 2d, That in so far as cases of double uterus and extra- 
uterine pregnancy are concerned, Superfoetation is established beyond 
question ; and 3d, That with respect to other cases (to which alone, 



190 PLURAL PREGNANCY. [CHAP. 

perhaps, the term Superfoetation should properly be applied), a large 
number of recorded cases are merely twin pregnancies. A strong pre- 
sumption is, therefore, established that, up to the period when the 
decidua reflexa comes into contact with thedecidua vera, and, probably, 
until the two have become intimately adherent, there is a possibility 
of a new impregnation. Beyond this period we believe it to be 
impossible. 



CHAPTER XL 

PLURAL PREGKAXCY— EXTRA-UTERINE PREGNANCY. 

plural pregnancy — mode of impregnation — twins: disposition of the 
membranes and placenta in: diagnosis of: relation of to superfceta- 
tion — triplets, etc. — extra-uterine pregnancy — varieties of: ovarian: 
tubal: tubo-ovarian : abdomino-tubal : tubo-uterine, etc.: abdomi- 
nal — CAUSES OF EXTRA-UTERINE PREGNANCY — DEVELOPMKNT OF THE OVUM 
AND ITS COVERINGS — SYMPATHY OF THE UTERUS — SYMPTOMS — PROGRESS OF IN 
DIFFERENT VARIETIES : RUPTURE OF THE SAC: PERITON EAL INFLAMMATION : 
DISCHARGE OF FC3TAL DEBRIS — TERMINATIONS — TREATMENT. 

The term Plural Pregnancy may be held to include all cases in 
which two or more germs are fertilized, simultaneously or nearly so, 
and are together developed within the uterine cavity. The products 
of conception in these cases are termed twins, triplets, quadruplets, etc., 
according to their number. It has been observed that certain women 
are peculiarly prone to plural conceptions ; that those, for example, 
who have once borne twins are much more likely to carry two children 
again than those who have not. Whether such pregnancies are or are 
not the result of separate acts of insemination, is a question in regard 
to which we cannot venture beyond conjecture. Many facts, such as 
the birth of twins of different color, have been observed, which seem 
to show that successive acts within a limited period may be the cause 
of the impregnation of separate ova. But it is in the highest degree 
improbable that this is always the case, for there is no reason to believe 
that, if the semen comes into contact at the same time with two mature 
ova, one only is to be fecundated, and the other passed over. Indeed, 
in cases of double yolk, where twin pregnancy occasionally arises, it is 
apparent that what may suffice to fecundate one germ, can scarcely fail 
similarly to act upon the other. We shall not pause here to consider 
whether or not we are to explain the fact of the frequent unequal de- 
velopment in multiple pregnancies by the doctrine of superfecu Delation, 
but nothing is so common in this class of cases as to find one child well 
developed and vigorous, while another is weak and puny. 

Twin Pregnancies occur once in about 75 to 80 cases, and triplets 
certainly not oftener than once in 5000. Cases where the number of 



XI.] TWIN PREGNANCY. 191 

children is greater are extremely rare. It was for long doubtful 
whether two embryos which were being simultaneously developed 
belonged to the same or different ova, and whether, in the last case, 
these ova proceeded from the same ovary. Modern research has in 
reference to these points established the following propositions : 1st, 
that two yolks are occasionally found in a single ovum ; and that the 
germs contained in them are probably simultaneously fertilized : 2d, 
that two ova may exist within a single Graafian vesicle, from which, 
on its maturity, they may escape and be fertilized, together or suc- 
cessively : 3d, that two ova may be formed within two Graafian vesicles 
in the same ovary, or one in each ovary, the latter of w T hich is proved 
by the simultaneous occurrence of pregnancy in each cavity of a double 
uterus (see Dr. Ross's case, quoted in Chap. X), and by the existence of 
two corpora lutea, in the same stage of development. 

The following varieties of twin pregnancy, — the distinction between 
which depends on the arrangement of the membranes, cord, and pla- 
centa, — are those which are generally observed in practice. The essen- 
tial difference between them depends, as a little careful examination 
will show, upon whether two ova have been separately impregnated, or 
a single ovum has contained two germs.. 

The cases which occur most frequently are those in which two dis- 
tinct ova are impregnated, whether they come from separate ovaries, 
from two Graafian vesicles in one ovary, or from a single Graafian 
vesicle. Each of these becomes imbedded in the mucous membrane of 
the uterus, and the decidua reflexa rises round it in the usual way. In 
the process of growth, the two tumors approach each other and come 
into contact, forming thus a partition between the two cavities, which 
originally consists of six layers, the decidua, chorion, and amnion, 
proper to each embryo. It would seem, however, according to the 
observations of Guillemot and others, that the decidua forms a very 
thin layer in the partition, or is absorbed, so that the partition at 
maturity consists of four layers only, consisting of the amnion (3 3) 
and the chorion (2 2) on each side, the whole mass being enveloped in 
a single decidua (1 1). In these cases the placenta?, developed, as will 
be remembered, on the maternal and foetal sides, from the decidua and 
chorion respectively, are sometimes completely separated, the one from 
the other. In other instances, again, they are fused together into a 
single mass, or are united by a sort of membranous bridge. But, as a 
rule, in spite of this continuity of tissue, there exists no vascular com- 
munication between the two. 

In another class of cases, which are of comparatively rare occurrence, 
there is a chorion (Fig. 92, 2 2) common to both embryos, each, how- 
ever, being inclosed in its own amnion (3 3), the common decidua 
(1 1) surrounding the whole, as in the former case. In these instances 
there is a single placenta, and very frequently ramifications exist be- 
tween the branches of the two cords. There can be no doubt that here 
there must have been impregnation of two germs within a single 
ovum ; or, in other words, they are cases of double yolk. 

It occasionally occurs that two embryos exist in a common amnionic 
cavity, — a fact which it is difficult to explain on any other hypothesis 



192 



PLURAL PREGNANCY. 



[CHAP. 



than that they originally belonged to the former class, and that the 
amnionic partition in Fig. 92 is absorbed in the course of development. 
If we could admit that the doctrine propounded by M. Serres was 
correct, — that the amnion exists, in the first instance, as an independ- 
ent vesicle, and that, subsequently to its complete development, the 
foetus comes into contact with it, and depresses its surface so as to 
envelop itself in a double layer, as takes place in the case of the serous 
membranes and the viscera which they invest, — we might be able to 



Fig. 91. 




Diagrammatic representation of 
partition in twin pregnancy (1st 
variety). 




Twin pregnancy (2d variety). 



explain the occurrence. In the present state of our knowledge, how- 
ever, on the subject of Ovology, we are at a loss to account for the 
presence of two embryos in one amnionic sac on any other theory than 
that which we have mentioned. But we cannot agree witli those who 
pronounce it to be impossible, or irreconcilable with the views of de- 
velopment which have been given in an earlier section of this work. 
For, while we are constrained to admit the improbability, we cannot 
subscribe to the impossibility, of the development of two embryos on a 
continuous surface of the germinal membrane, — both being included 
within the cavity formed, in the usual way, by the amnionic folds. 
The two cords have generally been observed, in these cases, to spring 
from separate points of the placenta; but they have been found, in a 
few rare instances, to spring from a common trunk, which bifurcates at 
a variable distance from the placental surface. In the cases of twin 
pregnancy in which one fetus is deprived of an important part of its 
body, it has been frequently found along with a perfect twin in the 
same amnionic sac. 

A fourth variety of twin conception is that which has been described 
by Olivier and others, under the name of monstrosity by inclusion. 
This consists in the presence within an otherwise perfect foetus of the 
elements, more or less distinct, of another, which may be situated 
either within the abdominal cavity, or beneath the skin — usually in 
the neighborhood of the perineum or scrotum. 

It is often possible, during the currency of a pregnancy, more espe- 
cially during the weeks immediately preceding delivery, to recognize 
the presence of twins. Generally speaking, when there is, as is usual, 
a foetus on either side of the uterus, the shape of the organ is less 
globular than usual, and there is more enlargement in the direction of 
the sides. The woman may complain of movement at separate points 



XI.] RARER VARIETIES. 193 

of the abdomen, — an observation which, although far from being con- 
clusive evidence of the presence of twins, seems to be, in certain cases, 
of some practical value as a symptom. If the abdominal wall be thin, 
it may also be possible for the accoucheur to perceive these movements 
by palpation, and, in the course of the same examination, even to recog- 
nize the presence of a second foetus. There is greater distension of the 
abdomen, and an aggravation of such symptoms as are the result of 
pressure on neighboring organs. The pulsation of the two foetal hearts 
may be heard at different points on the abdominal surface. Ballotte- 
ment is not practicable. The uterine souffle is unaltered. These signs 
are, however, often vague and unsatisfactory, even in those cases in 
which a suspicion of twin pregnancy has arisen ; and, in the majority 
of instances, the fact of the plural pregnancy is only recognized in the 
course of labor. 

Whether as the result of superfecundation, or simply of unequal de- 
velopment, cases are very frequently met with in which the infants are 
of different size. In others, the growth of one foetus is arrested, and 
it dies. The results, in such cases, vary considerably, being influenced 
by various circumstances, among which we may assume that the mode 
of disposition of the membranes is not the least important. In a cer- 
tain number of cases, the dead foetus is retained, but there being no 
access of external air, no putrefactive change takes place. It becomes 
hard, withered, and mummified, and in this state it may be born with 
the mature foetus at the termination of pregnancy. This may happen 
whatever may be the nature of the partition between the two, and even 
as some believe, in the cases in which they are in a single amnionic 
cavity ; but it is, we apprehend, likely that Baudelocque is correct, 
when he assumes that, in the latter, the death of one necessarily places 
the life of the other in great jeopardy. In other instances, the dead 
foetus acts as a foreign body, or in some other way incites the uterus to 
contract, the result being usually the expulsion of the living and the 
dead ; or the dead foetus is expelled, and the uterine action being 
arrested at this point, the living one is retained, and ultimately fully 
developed. This can, for reasons which a moment's reflection will 
render obvious, only take place when each foetus is enveloped in a 
complete series of membranes. If there be a common chorion, and, 
a fortiori, if there be a common amnion, the expulsion of one necessa- 
rily involves the expulsion of the other. In yet another group of 
cases of this nature, both are retained ; but when labor comes on, the 
mature and living child only is expelled, while the withered foetus 
remains behind, and may possibly occupy the womb for a very con- 
siderable period. The cause of the death of one foetus in these cases 
is not well understood, but, probably, they who believe it to be due to 
some form of degeneration of the placenta or the membranes, or to some 
disease in the foetus itself, are correct in their supposition. 

It has been observed, with reference to multiple pregnancies, that 
they frequently terminate before the full period of gestation has been 
reached. This we may assume to be due to the over-distension of the 
uterus, which excites it to contraction at a period somewhat earlier than 



194 EXTRA-UTERINE PREGNANCY. [CHAP. 

usual. As a rule, both children are generally expelled in the course 
of the same labor, in some instances without even a pause in the uterine 
effort. This is, however, far from being invariable, as it is not uncom- 
mon for the action to cease, and to return again in eighteen, twenty- 
four, or even forty-eight hours, when the uterus is thrown anew into 
periodic contractions, and the labor goes on in a perfectly regular and 
normal manner. In very rare cases, the interval between the two births 
may extend to a period of weeks, or even of months ; and there can 
be no doubt that many of these cases have given rise, on erroneous 
grounds, to a belief in the theory of superfoetation, the error arising 
from the fact that the immaturity of the first child is overlooked. 

It is unnecessary to make further mention of the other varieties of 
multiple pregnancy, as the observations which have been made may be 
held mutatis mutandis, as applicable to these also. To judge from the 
few cases in which observations have been made, it would appear to be 
rare that each foetus, the number being more than two, is inclosed in 
its own complete sac. Several cases of triplets, are, for example, re- 
corded, in which one had a special sac, while the other two had a com- 
mon amnion. In regard to the possible retention of one or more 
of them, we may well suppose, to judge from analogy, that any con- 
ceivable combination of the numbers is in this respect possible. The 
practical bearing of plural pregnancy on the progress of labor will be 
noticed hereafter. 

Extra-uterine Pregnancy. — Although the cavity of the womb is the 
site which nature has specially prepared for the development of the 
fruit of conception, it occasionally happens that it goes through its 
characteristic phases of development elsewhere. Generally, in these 
cases, its growth is arrested at a stage considerably short of maturity ; 
but many instances have occurred in which the full period of gestation 
has been reached, and some in which it has been considerably exceeded, 
although the cavity of the uterus was entirely empty, as in the virgin 
state. The ovum is, as has been shown, developed within the ovary in 
the Graafian vesicle; and what has been observed in the lower animals 
leads us to conclude that, while yet it occupies that situation, and even 
before the rupture of the vesicle has occurred, impregnation may take 
place. On the bursting of the vesicle, the germ is received into the 
infundibulum or pavilion of the Fallopian tube, and is thence con- 
ducted slowly through the entire length of the tube, until it reaches 
the uterine cavity, where its subsequent development progresses until 
the moment of delivery. Such we know to be the law of nature. Con- 
stituting an exception to this law, the ovum may, however, be arrested 
at any point of its course, and there, taking root as it were, the vital 
processes of development go on, up to a certain point, as actively and 
as efficiently as if the ovum had passed on to its usual site. In other 
cases it may deviate from its normal channel, and escaping between the 
fimbria? of the Fallopian tubes, falls into the cavity of the peritoneum, 
to some portion of which membrane it attaches itself. These are the 
circumstances which constitute extra-uterine pregnancy, and cases as 
they occur are classified more or less elaborately according to the ana- 
tomical relations which the ovum assumes in its unwonted situation. 



XI.] TUBAL PREGNANCY. 195 

The usual division is into Ovarian, Tubal, and Abdominal cases, with 
many subdivisions, the more important only of which will be noticed. 

The existence of Ovarian pregnancy has, by Mayor, Velpeau, and 
others, been absolutely denied. The denial seems, however, to have 
been founded on the assumption, which we believe to be unwarranted, 
that impregnation is mechanically impossible without rupture of the 
Graafian vesicle. But, even if rupture has taken place, it is not incon- 
ceivable that a fertilized ovum should remain, and become, at least 
partially, developed within the Graafian vesicle. This is what has been 
termed the "internal" variety of ovarian pregnancy, as distinguished 
from the " external" form, in which the ovum is attached to the surface 
of the ovary. It is probable that, while the latter may more properly 
be classed as " abdominal," or " tu bo-ovarian," it is the former alone 
which should receive the name of "ovarian" pregnancy; but it must 
be confessed that, in this sense, internal or true ovarian pregnancy 
involves an assumption which, among modern physiologists, receives 
little support. 

Of all the varieties of extra-uterine gestation, the most common, by 
far, is the Tubal, which, for the reasons, already stated, is precisely 
what we would anticipate. The ovum is, in its descent towards the 
cavity which awaits it, arrested, it may be at any one point of its 
course, and there contracts adhesions, forms its membranes and pla- 
centa, and is thus surrounded, in lieu of a uterus, with a sac which is 
formed of the dilated and hypertrophied walls of the Fallopian tube. 
For greater precision in description, various names have been assigned 
to such pregnancies, according to the exact point at which the arrest 
of the ovum takes place. Those quite at the fimbriated extremity of 
the tube, which either are originally, or come to be in course of time, 
in contact both with tube and ovary, are termed tubo-ovarkm. Where, 
again, the ovum is stopped at the point where the tube first narrows, 
the fimbriae having relaxed their hold on the ovary, the development 
may take place partly within the tube, where the placenta will probably 
be situated, and partly bulging into the abdominal cavity, in which 
direction the growth mainly advances. To this variety the name tubo- 
abdominal has been given. Between this and the uterine wall is the 
situation at which the ordinary and most common form of tubal preg- 
nancy occurs. Several varieties have been described of cases in which 
the ovum has its seat in the immediate vicinity of the uterine cavity, 
of which the most important and interesting is the utero-tubal, where 
the ovum lodges in that portion of the tube which passes through the 
walls of the uterus. The development in such a case may be partly 
within the uterus and partly within the tube; or, when a little more 
external, it may develop actually within the parenchyma of the uterus, 
and, if projecting into the cavity, may be invested with a covering of 
muscular fibres derived from the uterus itself. This is, probably, the 
Graviditas in substantia uteri of the older writers. 

Among the rarer varieties is that, of which an example is given by 
Burns, in which the placenta is found in its normal situation within 
the uterus, and the foetus within the Fallopian tube ; and, still more 
rare are those of which Hunter, Horfmeister, and Patuna have given 



196 EXTRA -UTERINE PREGNANCY. [CHAP. 

illustrations, in which the foetus has been found in the abdominal 
cavity, and the placenta in the uterus — the two being connected by a 
cord which ran from the placenta for some distance within the Fallo- 
pian tube, and then perforated it to join the foetus. These latter cases 
have been called utero-tubo-abdominal ; and, in reference to them, it is 
in the highest degree probable that they were originally cases of tubal 
pregnancy, in which the placenta had been developed within the uterus, 
while the foetus had escaped into the peritoneum by rupture of the 
walls of the sac in which it had been contained. Another rare form 
has been described as subpcritoneo -pelvic ; in which it is assumed that 
the ovum, having been unable to enter the external orifice of the tube, 
has got between the folds of the broad ligament, and there developed 
itself. It has been justly observed that, if this variety does occur, a 
more favorable result may be anticipated than in the other forms ; 
beeause, in such a situation, the debris of a dead foetus may be more 
easily and more safely removed. 

In Abdominal Pregnancy, the fertilized ovum escapes the grasp of 
the fimbriae, and falls into the cavity of the peritoneum, to any portion 
of which membrane it may in fact become attached. We may thus 
find it firmly incorporated with the broad ligament, the intestines, the 
colon, and any other parts to which continuity of tissue permits its 
access. The essential physiological difference between an abdominal 
case and the other varieties of extra-uterine pregnancy is that, in the 
former, the ovum is without any special covering which can correspond 
to that which, under other circumstances, it derives from the tube or 
other investing structure. It grafts itself, so to speak, upon the 
peritoneal surface of some viscus, or of the abdominal wall; and if it 
is subsequently covered with any special covering, that must be the 
result, physiologically, of special evolution, or, pathologically, of in- 
flammatory action. 

Little has been hitherto discovered which enables us to come to a 
satisfactory conclusion, in regard to any of the above varieties, as to the 
Causes of extra-uterine gestation. Many have believed that a shock or 
fright, or a blow on the lower part of the belly may, should this chance 
to coincide with the moment of conception, give rise to it, and they 
ground this belief on facts which women have from time to time com- 
municated. No single observation affords, however, to this theory, 
even the shadow of a proof, and the so-called evidence on which it 
rests, may perhaps be attributed without impropriety to that love of 
the marvellous which exists in so many minds. We cannot doubt that 
certain pathological conditions might furnish the cause; and, in some 
instances, the existence of such pathological conditions has been estab- 
lished. Inflammatory action of any kind, induration, pressure exer- 
cised by morbid growths, spasm of the muscular fibres of which the 
tube is so largely composed — so as to cause stricture — are a few of a 
hundred conditions which might be specified as possible causes of the 
phenomenon. The fact is, however, that in most of the cases in which 
a careful examination has been made, the course of pregnancy so alters 
the anatomical conditions of the chosen site, that it is impossible to 
come to any satisfactory conclusion as to the original condition of the 



XI.] POSSIBLE CAUSES. 197 

parts. Some very curious phenomena have been observed, showing 
that the ovum is sometimes very erratic in its course. How otherwise 
are we to explain the facts observed in Dr. Oldham's cases, in which 
there was a distinct corpus luteum on one side, and tubal pregnancy on 
the other? for we must accept, as Dr. Tyler Smith says, in reference to 
one of these cases, one of three explanations. "The unimpregnated 
ovule might have been swept by the cilia of the peritoneum from the 
right ovary to the fimbriated extremity of the left tube; this would be 
similar to what occurs in the Amphibia, in which the ova always 
traverse the abdomen to reach the oviduct. Or the left tube may have 
reached over to the right ovary and have taken up the ovule. Accord- 
ing to the third explanation it might be that the ovule has descended 
the right tube, entered the uterus, and then ascended through part of 
the left tube by an antiperistaltic action, or by the ciliary currents 
which move from below upwards." The view which Dr. Smith pre- 
ferred in regard to the case in question was the third ; while Dr. Old- 
ham and Mr. Wharton Jones were inclined to accept rather the second 
of the explanations offered. It is possible that some cases of extra-uterine 
pregnancy may owe their origin to some such peculiarities in the evolu- 
tion of the ovule. 

In every form of extra-uterine pregnancy, the ovum forms its own 
membranes, and goes through the various phases of evolution in all 
respects as if the pregnancy were normal. It is therefore in every 
case covered by its own amnion and chorion, without which, indeed, 
further development were impossible. For, if we reflect on the man- 
ner in which the main circulation of the embryo is established through 
the agency of the latter membrane, we cannot by any possibility agree 
with those who have maintained that in abdominal pregnancies there 
is no chorion. So far all cases are alike. But in regard to the further 
coverings of the foetus which, external to those just named, are of 
maternal origin, and correspond to the decidua and the uterus, great 
differences exist according to the class of extra-uterine pregnancy to 
which each case is to be referred. It is probable that in tubal preg- 
nancy the mucous membrane may form, as in ordinary cases, a special 
envelope strictly analogous to the decidua ; but, whether we take this 
view of the case or not, it is clear that, in every instance, the sac within 
which is contained the foetus and its special structures, is composed 
of the mucous, muscular, and serous layers of the Fallopian tube, which 
become distended, and at the same time hypertrophied, as the ovum 
grows. In true ovarian pregnancy, if such indeed exist, the sac must 
consist originally of the walls of the Graafian vesicle, and externally of 
the special coverings of the ovary itself; but, in the compound forms, 
the sac may be partly tubal and partly ovarian, or partly tubal and 
partly uterine, the covering depending simply in each case upon the site 
at which the ovum becomes arrested. 

Cases of Abdominal pregnancy differ materially from all others in 
this respect, and stand on that account in a class by themselves. The 
ovum is not in this variety arrested at any point of the canal through 
which nature intended it to pass ; but escapes altogether from that 
canal and falls naked into the great abdominal cavity, without any 



198 EXTRA-UTERINE PREGNANCY. [CHAP. 

special covering whatever, unless it be some remains of the granular 
disk in which it was imbedded. Here, in the early stage at least, there 
can be no special covering, nor connection with the maternal parts 
other than mere juxtaposition, the result of gravity or some other 
accidental circumstance. If the ovule has not, prior to this, been 
fertilized, it will no doubt rapidly disappear, and be absorbed with the 
secretions of the peritoneal surface. But, if on the other hand, an 
independent vitality has been communicated to it by conception, it 
bears the life which it contains to some point accidentally selected, and 
having there grafted itself upon the subjacent part, the essential contact 
between the maternal and foetal systems is established, and the subse- 
quent stages of development ensue. There can thus be, in the first 
instance, no sac whatever; and although it is not impossible that a 
special sac might be developed from the peritoneal surface, as under 
ordinary circumstances takes place from the mucous membrane of the 
uterus, no facts have hitherto been observed to show that the ovum in 
abdominal pregnancy has any sac external to the chorion. But, should 
rupture of the membranes of the ovum occur, the embryo, which usually 
escapes into the abdominal cavity along with the liquor amnii, instantly 
becomes a foreign body; and, by exciting inflammatory action, pro- 
vokes the development of coagulable lymph. This, under favorable 
circumstances, may form a sac around the ovum, inclosing it now in 
a special cavity, and protecting the rest of the peritoneal surface from 
the dangerous effects of extensive inflammation, which would inevitably 
ensue from the prolonged contact of the foetal remains. 

Whatever the site may be, abdominal or otherwise, at which the 
fertilized ovum takes up its position, the speedy result is a marked 
increase in the vascularity of the contiguous parts. If, for example, it 
becomes adherent to the peritoneal surface of any portion of the bowel, 
the bloodvessels of that part will at once become the seat of a marked 
and wonderful hypertrophy. What were before minute twigs now 
become large venous trunks, and the arterial supply is of course pro- 
portionally augmented. The vessels being projected from the embryo 
to the chorion by means of the allantois, the vascularity of that mem- 
brane is at once established. Those of its villi which belong to the 
visceral surface undergo marked development, and contract still closer 
adhesions with the peritoneum. The whole of the tissues become at 
this point enormously developed, and thus the placenta is formed, 
within which the interchange of gases and materials goes on smoothly 
and, for a time, safely. 

During the development of an extra-uterine foetus, certain changes 
more or less marked have been noticed to take place in the uterus at 
an early period of the pregnancy. These changes, in so far as they 
have hitherto been observed, seem to be identical with the preparatory 
process of which the uterus is the seat at the time of impregnation, 
and prior to the descent of the ovum. They consist in a marked in- 
crease in the size of the organ, in an equally marked increase in its 
vascularity, and in the characteristic thickening and hypertrophy of 
the mucous membrane, which is the first stage in the formation of the 
decidua. These symptoms are, however, of brief duration. The 



XI.] SYMPTOMS. 199 

uterus, not receiving the expected stimulus which would have been 
afforded by the ovum on its arrival, falls into a state of quiescence, its 
bulk and circulation being speedily restored, or nearly restored, to the 
normal standard. 

The symptoms of extra-uterine pregnancy are far from being defi- 
nite and distinct. Just at first, the changes which have been men- 
tioned as occurring in the uterus would, no doubt, tend to suggest the 
idea of an ordinary pregnancy. The woman may, at this time, enjoy 
perfect health, disturbed only by some of the sympathetic digestive 
disorders which are so familiar. No reliance can be placed on the ces- 
sation of the menses as a sign, as, from the narrative of recorded cases, 
it would appear that the discharge ceases in about the same proportion 
of cases as it persists, while, in another class, irregular uterine haemor- 
rhage seems to be looked upon, if coincident with the early symptoms 
of pregnancy, as having a certain diagnostic value. Very generally, 
from an early period of the pregnancy, abdominal pain is complained 
of. This may take the form of an intermitting pain ; but it is generally 
constant, and confined to a certain limited region, which may be any 
one point on the abdominal surface. As the case advances and the 
ovum grows, considerable discomfort may be caused by pressure, exer- 
cised by the tumor directly or indirectly on neighboring organs; 
causing, for example, if the tumor should encroach upon the pelvic 
cavity, difficulty in defecation and micturition. Morning sickness, 
and the various changes which have their seat in the breasts, are of 
usual occurrence ; and, as the case goes on, a tumor may be felt which 
resembles, more or less closely, the gravid uterus, but which is fre- 
quently more irregular in outline, and situated more to one side than 
in the middle line. At the proper time, quickening takes place, and 
is soon succeeded by the pulsation of the fetal heart. Should suspicion 
have arisen as to the nature of the case, it is probable that the absence 
at this time of the characteristics which are revealed in ordinary preg- 
nancy by a vaginal examination might throw considerable light on the 
case. 

[A careful study of the clinical histories of a large number of cases 
of extra-uterine pregnancy, appears to show, that the symptoms of this 
accident are not so vague, as the statements of the author would lead 
us to believe. During the first few weeks after conception, there may 
be no symptoms to attract the attention of either the patient or her 
friends. Sooner or later, however, often at the end of the fourth week, 
often not until the end of the second month, the woman is seized with 
a violent pain, usually described as colic, and situated in the hypogas- 
tric region, generally on one side. This pain is very severe, and often 
produces profound prostration, with pallor, cold, clammy perspiration, 
feeble or nearly imperceptible pulse, and even syncope. It is generally 
associated with marked, and even very great tenderness in the lower 
part of the abdomen, which has led some to mistake this condition for 
peritonitis. After a period of variable duration, from a few hours to 
one or two days in most cases, the severity of the pain diminishes or 
it may disappear entirely. The calm, however, is deceitful, for sooner 
or later another paroxysm sets in, and pursues the same course that 



200 EXTRA -UTERINE PREGNANCY. [CHAP. 

the first did. These attacks of pain continue to recur at intervals, 
until rupture occurs, or until after the fifth or sixth month of gestation. 
They sometimes continue to term. 

Appearing before the pain, with it, or immediately after it, is another 
very characteristic symptom. This is metrorrhagia. The quantity of 
blood lost varies from a slight discharge to an exhausting haemorrhage. 

The occurrence of these two symptoms in a woman, who is herself 
firmly convinced that she is pregnant, should always lead to the suspi- 
cion of extra-uterine pregnancy. If in addition to these a decidua 
should be discharged en masse or in pieces, or symptoms of rupture 
supervene, the diagnosis is almost absolute. Even thus early an extra- 
uterine tumor can be discovered. At the end of the third month the 
child has been detected by ballottement. 

After the foetal heart can be heard, all doubts about the woman being 
pregnant are removed. It will now be found that the foetal tumor is 
developed upon one side, that its contents are very superficially situated, 
and that in some, but not all cases, the sac is immovable. By vag- 
inal examination the uterus is found to be displaced. The os is gen- 
erally carried forwards and upwards, so that it is often pressed against 
the symphysis pubis, or the anterior abdominal wall, some distance 
above the pubis. It is often reached with great difficulty, or cannot 
be found at all. At the same time an elastic or fluctuating tumor 
forms in the pelvis behind the uterus. This retro-uterine fulness with 
anterior displacement of the womb should always lead to the suspicion 
that the child is being developed outside of the uterus, providing the 
existence of pregnancy has been established. Another important 
symptom is the small size of the uterus, which, while it becomes more 
or less enlarged, is not developed in proportion to the duration of the 
gestation. Great care has, however, to be exercised in making this 
examination, to avoid being misled by the condition of the os and 
cervix. During this stage the spasmodic pains and metrorrhagia, so 
often present during the first three or four months of gestation, are 
likely to have ceased. — P.] 

If the pregnancy goes on without accident or hindrance till the 
period which marks the ordinary limit of gestation, pains come on, 
which are periodic, and which are described by women who have 
already borne children as precisely similar to ordinary labor pains. 
" These pains," says Burns, " usually begin in the sac, and then the 
uterus is excited to contract and discharge any fluid it contains." This 
uterine effort, at the end of the ninth month, is a physiological fact of 
surpassing interest, and seems to us to afford strong corroborative evi- 
dence of the correctness of that theory which supposes that the cause 
of labor has its seat neither in the foetus nor in the uterus, but is, 
probably, to be found in the ovary, and is generally to be looked for 
at the tenth menstrual period after impregnation. In weighing the 
symptoms in a doubtful case, a fact which has already been mentioned 
in reference to the question of superfoetation should be borne in mind, 
viz. : that a second (uterine) pregnancy is quite possible ; and, indeed, 
a most striking case is quoted by Montgomery from Primrose, in 
which a woman went to the ninth month of her seventh gestation, 



XI.] SYMPTOMS. 201 

when labor came on as on former occasions, although, ultimately, it 
turned out that there was a prior abdominal pregnancy. 

The cases, however, in which extra-uterine pregnancy is prolonged 
till the ninth, or even the eighth month, form a very small proportion 
of the whole. It is, in point of fact, an unusual occurrence when de- 
velopment in such a case continues beyond the fourth or fifth month ; 
but, on the other hand, cases are on record, which are apparently au- 
thentic, in which the life of the foetus was prolonged within the 
abdomen for several months beyond the ordinary period. M. Desei- 
meris, whose memoir on this subject is justly considered as of great 
value, states that rupture occurs in more than three-fourths of all 
cases ; that, in the tubo-uterine variety, it takes place, as a rule, before 
the end of the second month ; in tubal, in the fourth month ; later in 
ovarian pregnancy ; and, in abdominal pregnancy, not till the eighth 
or ninth month. The usual crisis, then, in all such cases, which may 
arrive sooner or later in their course, is rupture of the sac and of the 
fcetal membranes, or of the latter alone in abdominal pregnancies. 

The symptoms which follow rupture of the sac are of extreme gravity, 
and the result invariably is that the life of the woman is placed in 
great jeopardy. The rupture is frequently preceded by severe pains, 
which may continue for several hours. A sudden cessation of these 
pains is then observed to coincide with a notable diminution in the 
size of the tumor. This is succeeded almost immediately by pallor, 
dimness of vision, vomiting, syncope, and other symptoms which indi- 
cate profuse internal haemorrhage. To these succeed loss of pulse, 
clammy sweat, convulsions, and death — or, the bleeding being arrested, 
the patient rallies and escapes the immediate danger of haemorrhage. 

If, after rupture of the sac, the haemorrhage is limited in extent, or 
if something occurs to check it by favoring the coagulation of the 
blood, death may not be immediate, but may, nevertheless, take place, 
as the result purely of haemorrhage, after an interval of some days : 
whereas, if the flow of blood be effectually barred, the patient may 
rally, and the symptoms of impending dissolution may disappear. But 
the danger which has thus been averted is forthwith succeeded by 
another equally grave. The foetus, the amnionic fluid, and the effused 
blood, arouse violent peritoneal inflammation, which rapidly runs its 
course, generally with a fatal result. Should the powers of nature be 
of sufficient energy to overcome this second assault, the effect of the 
inflammatory action is rather beneficial than otherwise, for the foetus 
now becomes inclosed in a sac, which is formed from coagulable lymph, 
and which effectually shuts it out from the rest of the abdominal 
cavity. Within the new cavity, a process of disintegration or modified 
decomposition goes on in the greater number of cases. 

[The views of the author in regard to the supervention of peritonitis 
after rupture of the cyst are in accordance with those which have been 
generally believed for many years. Clinical experience has shown, 
however, that peritonitis and consequent encystment of the escaped 
child, rarely follow rupture of the sac. Indeed, it so seldom happens, 
that Rogers, of New York, who has specially investigated this subject, 
is inclined to believe that it never occurs. Even when the woman 



202 EXTRA-UTERINE PREGNANCY. [CHAP. 

lives for several days, and presents all the symptoms of peritoneal in- 
flammation, that membrane is found pale and perfectly free from lymph 
at the autopsy. The accident is almost invariably fatal, but death is 
due to shock and anaemia. The process of elimination described by 
the author applies to cases in which the child has died in an unrup- 
tured cyst. — P.] 

The presence of the foetal debris -excites anew inflammatory action, 
extending probably to contiguous viscera, between which and the sac 
adhesions may be established. To this succeeds ulcerative absorption, 
resulting in the establishment of fistulous openings in the direction of 
the hollow viscera, or externally through the abdominal walls ; or per- 
foration may take place a second time into the peritoneal cavity, with 
little hope of any result other than a fatal one. But, if the perforation 
take the direction first mentioned, we may have, for weeks or months, 
portions of the more indestructible foetal structures, bones, teeth,. and 
the like, discharged through the abdominal wall, the vagina, the rectum, 
the bladder, or even the stomach ; and, if there be more than one fistu- 
lous opening, we may have portions successively or simultaneously 
discharged through two or more of the channels which have been 
enumerated. While the discharge of debris is going on, the inflam- 
matory action in the interior of the cyst continues, and is probably 
aggravated by the admission either of the external air, or of the con- 
tents of the hollow viscera into which the opening takes place. Irri- 
tative fever of a severe type is thus often set up, and to this, those 
women who have been so fortunate as to escape the dangers already 
specified may succumb. 

In some instances, the course and termination of extra-uterine preg- 
nancy is very different to what has been detailed. The pressure of 
the tumor may be productive of such annoyance and pain, or may 
interfere so seriously with the functions of neighboring organs, that 
the woman sinks and dies without any rupture having occurred; or 
even, in so far as can be ascertained, without the death of the foetus 
having preceded that of the mother. Or, as in another class of recorded 
cases, the child may die before rupture of the membranes has occurred, 
a result which we must look upon as favorable in the progress of these 
cases. For the first result of this is the arrestment of placental circula- 
tion, the dwindling of the enlarged vessels on the mother's side, and 
the consequent abatement in the risk from haemorrhage to which the 
woman is subjected. Under such exceptional circumstances, it is quite 
possible that no rupture of the original sac may occur. The foetus will 
then be retained without the occurrence either of haemorrhage or peri- 
toneal inflammation, but ultimately its remains will most likely be 
extruded by a similar process, and through the same channels as in the 
cases above mentioned. In some remarkable instances, the irritation 
caused by the presence of a dead foetus has been so inconsiderable as to 
permit of its residence for many years within the abdominal cavity, 
without causing any alarming symptom. It is probably in such cases 
that the putrefactive process undergoes the peculiar modifications which 
are manifested either by a withering or mummifaction of the foetus, or 
by a change which seems to be closely allied to adipocire. In many 



XI.] TREATMENT. 203 

of the recorded cases in which the fetus has been retained for an 
unusually long period, the sac would appear to have become the seat 
of calcareous deposit, which, by thickening and strengthening its walls, 
may be supposed at once to protect the foetus from external violence, 
and, at the same time, to protect the external parts, by rendering its 
rupture practically all but impossible. Burns mentions a case in which 
he had known the foetus retained for twenty years, and there have been 
instances in which it has been retained for a much longer period. 
Women, in some of these cases, have repeatedly become pregnant, and 
have been delivered of healthy children at the full time without dis- 
turbing the retained ovum. 

In regard to the Treatment of extra-uterine pregnancy, much must in 
every case depend on the stage of development and the other circum- 
stances of the case. In so far as the early weeks are concerned, it is 
obvious that, accurate diagnosis being impossible, treatment can only 
be palliative, or directed against symptoms, the import of which we can 
only guess at. At a stage somewhat more advanced, precision in 
diagnosis is scarcely more easy ; although, could we only be certain of 
this, we cannot doubt that the resources of modern surgery might avail. 
If the sac were lodged in the pelvis, interference would very probably 
take place with the functions of the bladder and rectum, requiring close 
attention to the state of the bowels, and perhaps frequent mechanical 
aid for the relief of the bladder. The attacks of pain, which are of such 
frequent occurrence in all the forms, will be most certainly and satisfac- 
torily removed by anodyne applications and by opiate suppositories or 
enemata, strict rest in the recumbent posture being at the same time 
enjoined, with careful attention to the digestive and other functions. It 
has been suggested by Cazeaux that, even at this early period, attempts 
should be made, by bleeding to syncope, or by electric shocks passed 
through the abdomen, to destroy the life of the foetus. Were this prac- 
ticable, it would be sound treatment, in view of the probabilities of 
the case, to cut short the existence of the foetus; but we apprehend 
that the result looked for cannot, with any confidence, be counted upon. 
It has also been recommended to perforate the sac by trocar from the 
vagina, should this be practicable, a step to which Scanzoni lends his 
powerful advocacy ; and we see no reason to doubt the propriety, in 
many cases, (if only diagnostic difficulties were overcome) of exhaust- 
ing the liquor amnii by means of the aspirator. 

When the period of expulsive effort arrives, it comes to be a question 
whether in any case we may interfere with a view to the relief of the 
patient by immediate delivery. The cases, doubtless, in which operative 
interference may be resorted to, with the greatest prospect of success, are 
those in which the foetus is felt through the vagina, and the nature of 
the case is distinctly made out; and, an additional argument in favor 
of operation will doubtless be afforded by proof of the life of the child. 
Besides there is always the chance that the case may be one of those 
which have been described as subperitoneo-pelvie. The operation, if 
resolved upon, consists in an incision through the vaginal walls, and 
the removal, by forceps or otherwise, of the foetus. By having recourse 



204 EXTRA-UTERINE PREGNANCY. [CHAP. 

to this procedure, the lives of infants have been, in a considerable 
number of instances, preserved ; but as a general rule, the mother has 
succumbed. 

If the pregnancy has reached the eighth month, and the life of the 
foetus is indicated by the usual signs, and, if the sac can be reached only 
through the abdominal walls, it is of course, possible to anticipate 
rupture, and to extract, by gastrotomy and incision of the sac, a living 
foetus. To this operation the name of Laparotomy has been given, and 
to its performance few obstacles or difficulties would seem to arise. 
But if we balance the hope of the child's life against what is almost 
the certainty of the mother's death, — which even under the most favor- 
able conditions, must be the state of the case, — there are, perhaps, few 
contingencies in surgical or obstetrical practice in regard to which the 
sense of responsibility will be more keenly felt. It is so far satisfactory 
to know, that recent experience has dispelled what was at one time 
believed to be the chief difficulty on the maternal side, viz., the removal 
of the placenta; and, indeed, it is now universally admitted that, if we 
perform the operation at all, we only augment the danger to the mother 
by any attempt to detach the placenta from the site to which it is 
adherent. There are cases in which this operation may be the only 
chance of the mother's life, and we are certainly entitled to hope that 
the great success which has of late years followed the operation of 
ovariotomy may point to the possible saving of lives which have hitherto 
been yielded up as hopeless. And, perhaps, a day may come when 
diagnostic skill being more certain, an early extra-uterine pregnancy 
may be removed and ligatured with as great a prospect of success as 
an ovarian cyst. Incases where a living mature child has escaped by 
rupture of the sac into the abdominal cavity, we need have no difficulty, 
for here the analogy is complete between the case in question and one 
in which a living child has similarly escaped through a uterine rupture ; 
and, by the operation in these circumstances, the risk to the mother 
will be little aggravated, while the life of the child may probably be 
saved. 

[The operation of gastrotomy to save a living and viable child 
cannot be too strongly condemned, unless the cyst has previously 
ruptured. A careful investigation of this subject has convinced the 
editor, that considering the child's and mother's lives of equal value, 
more human beings will be saved by trusting to nature, and meeting 
indications as they arise than by opening the abdominal cavity to pre- 
serve the life of the child. — P.] 

In the case of a woman who has carried for one or more years, an 
extra-uterine foetus, which causes her great suffering, or which is ob- 
viously undermining her general health, the question of operation may 
also suggest itself, although in a different form. The rule which must 
here guide us is, in addition to the state of her health, the possibility 
of reaching the tumor from the vagina; for, unless we were convinced 
of the existence of adhesions to the anterior or lateral abdominal 
walls, an operation in this direction would, we conceive, seldom be 
warranted. 

The duty of the surgeon will, however, in most cases, be confined to 



XII.] MOLAR PREGNANCY. 205 

carefully watching and cautiously assisting in the separation of the 
foetal debris. Should one or more fistulous openings exist in the 
abdominal walls, the vagina, the perineum, or the rectum, the nature 
and extent of the cavity of the sac may be carefully explored through 
them. By the aid of sponge-tents, the apertures may be safely dis- 
tended, and any loose portion removed; care being always taken not to 
drag rudely such fragments as may be adherent to the walls of the 
sac, as, by doing so, the sac might be ruptured, and peritonitis ensue. 
[These openings are more rapidly and more safely enlarged with the 
knife. This operation is one of little more gravity than opening a large 
abscess. — P.] If the communication has taken place in the direction 
of the bladder, it may be necessary to remove them by one of the opera- 
tions for lithotomy ; or, by dilatation of the urethra, as was done by Pro- 
fessor G. H. B. McLeod in a case which he communicated, many years 
ago, to the Medico-Chirurgical Society of Glasgow. While the separa- 
tion of the remains of the foetus is thus promoted, in any way which ex- 
perience may suggest to us as consistent with safety, the general health 
of the woman must be carefully attended to, her strength being sus- 
tained by nourishing food and suitable stimulants, while any tendency 
to hectic or irritative fever must receive its appropriate treatment. 



CHAPTER XII. 

ABNOKMAL DEVELOPMENT. 

MOLAR PREGNANCY — FALSE MOLES : FROM VAGINA : MEMBRANOUS DYSMENORRHCE A : 
FIBROUS AND HEMORRHAGIC CASTS OF UTKRUS — TRUE MOLES : FLESHY MOLES : 
HYDATIDIFORM MOLES — THEIR PATHOLOGY, DIAGNOSIS, AND TREATMENT — 
DISEASES OF THE PLACENTA, AND THEIR EFFECTS — MISSED LABOR — DISEASES 
OF THE FCETUS — INTRA-UTERINE FRACTURES AND AMPUTATIONS : EFFORTS AT 
REPRODUCTION — MONSTERS. 

There are, in addition to the peculiarities of development already 
noticed, certain others which deserve special notice in a systematic 
treatise, but which, nevertheless, are not unfrequently passed over as 
of no moment. There is every reason to suppose that these peculiarities 
have their origin, in a large proportion of instances, in actual disease 
of the ovum ; but whether this is, or is not, the primary cause of the 
affections in question, no doubt can, in the present state of pathological 
knowledge, be admitted, as to the frequent coincidence of disease or 
degeneration of the ovum, either with arrest of development, or with 
the transference of developmental energy to structures which are merely 
subsidiary. The result of this is the occasional expulsion from the 



206 ABNORMAL DEVELOPMENT. [CHAP. 

uterus of substances, the nature of which it is not always easy to deter- 
mine, and the origin and pathology of which have often been misunder- 
stood. These substances are generally termed Moles. 

It must be made clear, however, from the outset, that all solid mat- 
ters discharged from the uterus are not moles, properly so called. In 
other words, all such discharges are not the result of impregnation, — a 
fact which is of obvious medico-legal importance, and which imposes 
upon us the necessity of drawing a careful distinction between " true " 
and "false " moles. The matters which are discharged from the virgin, 
or which are independent of impregnation, and which might be mis- 
taken for the result of conception, form but few varieties, and constitute 
what are termed, with questionable propriety, False Moles. Under this 
designation may be included bodies, Avhich are composed mainly of 
the squamous epithelium of the vagina, thrown off in the form of 
flakes, or tubular casts ; and which may either be expelled singly, or 
form, by their union, masses of greater or less bulk, but seldom of any 
considerable size. A careful examination of these by the microscope, 
or even by the eye, will generally obviate the possibility of error; but 
as regards the following, the unwary may easily be misled. It is a fact 
familiar to every physician, that the most obstinate and intractable form 
of painful menstruation, or Dysmenorrhoea, is the membranous variety, 
in which the mucous membrane of the uterus is shed at each catamenial 
period, either in shreds of various size, or in the form of a single mass, 
forming a complete cast of the uterine cavity. In some rare instances, 
this occurs also independently of menstrual disorder. It may readily 
be conceived, that in such a case, accompanied, as it generally is, with 
haemorrhage and sustained expulsive effort, a suspicion of pregnancy 
and early abortion might arise in the mind, — the membrane in question 
being mistaken for the decidua, from which the embryo has escaped 
unobserved. In such a case, however, the true nature of the substance 
discharged may be disclosed by remembering that such an occurrence 
is not unusual at a menstrual period, and by obseving that all the usual 
and familiar signs of pregnancy are absent. It is, moreover, much 
less substantial in its texture, and more easily torn than the decidua, 
which has, under such circumstances, according to Montgomery, "a 
soft, rich, pulpy appearance, deep vascular color, and numerous well- 
developed utricular follicles or crypts, and foramina for the reception 
of the nutrient vessels from the uterus, which are always so distinctly 
observable. In one point, however, the dysmenorrhoea] membrane 
resembles the decidua, — having its inner surface smooth, and the outer 
unequal ; but it is of a ragged, shreddy appearance, unlike that of the 
healthy uterine decidua, and is, moreover, entirely destitute of the little 
cotyledonous sacculi described as an essential character in the latter 
structure." No trace of anything analogous to the transparent mem- 
branes of the ovum is to be discerned within it, nor does it contain a 
reflected layer, forming an inner pouch. When perfect, it presents 
three openings, — -one for each Fallopian tube, and one at the points of 
connection with the cervix uteri. 

A third variety of false mole has been described as occurring under 



XII.] TRUE MOLES. 207 

certain conditions of functional derangement of the uterus, more espe- 
cially when this is accompanied with some form of inflammatory action. 
In it, the substances expelled are of a fibrinous appearance externally, 
of a firm consistence, and varying greatly in size, but frequently pre- 
senting the form of a cast of the uterine cavity. Most frequently these 
are composed of blood-clots, which have become condensed and altered 
in appearance by their decolorization externally. In certain cases, 
they appear to be composed partly of clot and partly of lymph; while 
in others, which have been carefully observed, it would appear that a 
membranous cast has been surrounded by an outer layer of condensed 
coagulation. 1 

The True Moles differ from the above essentially in this, that they 
are in every instance the result of conception, in which, generally, the 
embryo has been blighted, and yet development of the membranes has 
progressed with abnormal activity. In the investigation of these cases, 
it is of importance to remember what Smellie tells us. "Should the 
embryo die," he says, "(suppose in the first or second month) some 
days before the ovum is discharged, it will sometimes be entirely dis- 
solved, so that when the secundines are delivered there is nothing more 
to be seen. In the first month, the embryo is so small and tender that 
the dissolution will be performed in twelve hours ; in the second month, 
two, three, or four days will suffice for this purpose." If this is the 
case when the ovum is expelled shortly after the death of the embryo, 
it need not astonish us that Avhen it is retained for a considerable period 
all trace of embryo has disappeared, while the membranes are so de- 
generated or metamorphosed that it is only with difficulty that the 
true nature of the case can be recognized. 

Of the highest interest and importance in reference to this subject, 
and more especially to the question of etiology, are the hemorrhagic 
discharges of which the ovum is the seat. In addition to the direct 
effect, which must spring from the sudden abstraction of blood either 
from the foetal or maternal vessels connected with the ovum, the blood 
which flows from the ruptured vessels very frequently exercises a me- 
chanical influence in the separation of contiguous parts with the most 
disastrous results. Blood may thus be interposed by the rupture of 
the utero-decidual vessels, and so cut off the only maternal supply pos- 
sible for the early embryo. Or, at a later stage, haemorrhage from the 
utero-placental vessels may so engorge the parenchyma of the placenta, 
as to cause apoplexy of that organ, an affection which we shall have 
occasion hereafter to mention. Again, the extravasation may take 
place between the chorion and the clecidua reflexa, or even within the 
amnion, destroying the embryo and giving rise to abortion. Particular 
attention has been given by Scanzoni to the various forms of apoplexy 
of the ovum, a subject which is of interest to us at this stage, as a 
cause not only of death of the embryo, and of abortion, but also of the 

1 These formations are fully described and admirably depicted by Dr. A. B- 
Granville, in his admirable monograph on Abortion and the Diseases of Menstrua- 
tion. 



208 ABNORMAL DEVELOPMENT. [CHAP. 

formation of true moles, when abortion does not at once ensue. His 
conclusions as to the progress and termination of the haemorrhage are as 
follows : 

" 1. If the flow of blood is simply from the utero-placental or utero- 
decidual vessels, and the quantity is inconsiderable, this does not suffice 
to separate the ovum in the greater part of its circumference, or by 
mechanical pressure to arrest its further development ; so that blood 
effused between the uterine walls and the decidua, or even between the 
two layers of the latter, may be either completely or, at least, partially 
reabsorbed, and the pregnancy may reach its normal termination. 

" 2. But if the quantity of the effused blood is considerable, the 
ovum is separated from the uterine walls either entirely or to a great , 
extent, and is compressed by the voluminous coagulum, and more or 
less flattened ; such compression actually causes bursting of the mem- 
branes (of which Dubois narrates a case), when abortion is the usual 
result. 

" 3. The same is the result when the foetus dies through rupture of 
its own vessels and the placental haemorrhage thus induced. Here 
also the abortive ovum is expelled, the rapidity with which the abor- 
tion occurs depending especially on the occurrence of simultaneous 
uterine haemorrhage. 

"4. The ovum may, as is much more rarely the case, remain with 
the dead foetus for a considerable time in the uterine cavity ; the coagu- 
lum undergoes certain changes, which are also observable in extrava- 
sation in other parts of the body, and so gives occasion for the origin 
of the formation known under the name of Fleshmole." 

The Fleshy Mole (Mole Carnosa) is probably formed in part from 
coagula and in part from the membranes of the ovum, which undergo 
a species of degeneration by some such series of changes as the follow- 
ing : The effused blood becomes in the first instance decolorized by 
rupture of the blood-corpuscles and absorption of their coloring matter. 
This decoloration takes place from the centre towards the circumfer- 
ence. The fibrin, as Scanzoni supposes, becomes transformed into 
cellular tissue, by means of which communication is established between 
the external lining of the ovum on the one hand, and the inner surface 
of the uterine wall on the other, — so that the further development of 
the structures thus in apposition is rendered possible. We may as- 
sume that in these cases complete separation of the ovum cannot have 
taken place, otherwise the death of the whole structures of the ovum 
would have rendered its expulsion inevitable. And, as the connection 
between the uterus and the ovum is most firm at that part where the 
placenta has either formed or is about to form, the probability is that 
the vascular supply sent to the ovum through this channel is never 
entirely cut off. On the establishment of new and more extensive 
adhesions, the blood supply is at once augmented, and the membranes 
and effused coagula become intimately bound together into a mass, 
through which vessels freely run, and which becomes hypertrophied 
to a very considerable extent. It would appear that, at least under 
certain circumstances, the chief seat of the carneous degeneration is the 



XII.] THE HYDATIDIFORM MOLE. 209 

decidua vera; for, it is certain that in many of the cases which have 
been most carefully examined, the structure of the chorion has been 
distinctly recognized by its villi, although the membrane itself had 
undergone some considerable thickening. The villi in these cases have 
been found to consist of molecular masses and fat-cells. The amnion' 
undergoes little change, and may be found adhering to the inner sur- 
face of the chorion, and containing within its cavity a certain quantity 
of bloody fluid, in which will be found what remains of the embryo. 
The rudiments of the embryo are, however, frequently very indistinct, 
unless the pregnancy should chance to have been more advanced than 
usual; and, indeed, difficulty will frequently be experienced in tracing 
even the remains of the cord, although the chorion and amnion may 
be tolerably distinct. The nature of the case will nevertheless usually 
be recognized on a careful examination, by the discovery of the villi 
of the chorion ; and Scanzoni asserts further that in the cases examined 
by him he has never failed to discover the enlarged villi by the agency 
of which the placenta was already going through the earliest stage of 
its formation. While in all these cases the diseased membranes go 
on increasing in bulk, they are of course rendered quite unfit for the 
discharge of their primary functions, so that the contained embryo, if 
its death has not preceded the degeneration, must speedily succumb. 
" When the growth of the ovum," says Rigby, " proceeds after the 
destruction of the embryo, it increases very rapidly in size, much more 
so than would be the case in natural pregnancy, so that the uterus, 
when filled with a mole of this sort, is as large at the third month as 
it would be in pregnancy at the fifth." As the development of the 
mole goes on, it increases in density as well as bulk, and the growth 
may continue for three or four months, until its presence within the 
uterus awakens expulsive efforts, when it is speedily expelled, present- 
ing the characteristics just detailed. 

Cases occasionally occur in which fatty degeneration is the most 
conspicuous characteristic of a mole; but this we may merely mention 
as a variety of the fleshy form ; and the same remark may be made in 
regard to what has been described by the German authors as " Stein- 
mole" a yariety which seems to attend a retention of the mole within 
the uterus for an unusually long period ; and which implies, as its 
name indicates, a calcareous degeneration of what was, in all proba- 
bility, originally an ordinary fleshy mole. With reference to such 
cases, it may, however, be remarked, that such calcareous masses are 
to be cautiously received as evidence of mole pregnancy, unless the 
characteristics of the latter are clearly manifested. For we know that 
fibroid tumors of the uterus are also subject, although rarely, to a simi- 
lar degeneration ; and it is quite within the bounds of possibility that 
an error of some magnitude might here be committed, seeing that these 
concretions are sometimes spontaneously separated from the uterus, 
and discharged through the vagina. 

The Hydatidiform Mole. — The bodies which form the distinguishing 
feature of these moles were long supposed to be true hydatids, formed 
in, and discharged from the uterus. More careful examination showed, 

14 



210 



ABNORMAL DEVELOPMENT. 



[CHAP. 



Fig. 93. 





K) 



Hydatidiform degeneration of ovum. 



however, that they were not, like true hydatids, closed sacs within one 

another, but that the vesicles were arranged 
in a manner quite different from this, each 
saccule growing from another, in regard to 
which it is either sessile, or connected by 
a pedicle of varying length. In this man- 
ner cyst grows out of cyst, and the pedicles 
do not unite them with principal stems, 
but with each other, so that, as Metten- 
heimer and Barnes have shown, it is in- 
correct to compare them, with Gooch, to 
currants, or, with Cruveilhier, to a bunch 
of grapes. The arrangement is very well 
shown in the annexed representation of a 
mass of these bodies which had been ex- 
pelled from the uterus. The vesicles vary 
considerably in size, from a walnut down- 
wards, according to the development which 
they have attained, or the distance at which 
they are situated from the parent cyst, from 
which they originally spring. Not u infre- 
quently, when they escape unexpectedly, 
they are brought under the notice of the 
practitioner floating in a basin of water, 
and discolored with blood ; and under 
these circumstances the graphic description of Gooch is singularly 
applicable, for they then resemble very closely a mass of " white cur- 
rants floating in red currant juice." 

Although the exact mode in which the vesicles constituting the hyda- 
tidiform mole are formed is not yet clearly fixed to the satisfaction of 
all, there is one point in which all modern authorities are agreed, viz., 
that they spring from the villi of the chorion. It is also admitted 
that in this, as in the fleshy mole, we have no new formation, but 
simply an alteration and degeneration of previously existing structures. 
But when we come to consider the pathological process by which this 
alteration is effected, Ave find that considerable differences of opinion 
exist. The views on this subject originally propounded by Metten- 
heimer in 1850, in Mullens Arehiv, and which have been indorsed 
in this country by Paget and Barnes, are those which are generally 
entertained. The villi of the chorion, as has been pointed out by 
modern physiologists, grow normally by a process of gemmation, bud 
springing from bud in successive stages of growth. Under the influ- 
ence of perverted development, these buds, or the elementary cells of 
which each villus is composed, take on a new action, and become trans- 
formed into vesicles, which vary in size, and to which attaches the 
power of repeating the process of chorion development, still in a per- 
verted sense, until the so-called hydatidiform mass is formed. Gierse 
is of opinion that the change consists in hypertrophy of the normal 
structures found in the chorion villi, with secondary oedema ; and Dr. 



XII.] THE HYDATIDIFORM MOLE. 211 

Graily Hewitt urges that the vesicular transformation is a consequence, 
and not a cause , of the death of the embryo, and that it is therefore 
nothing more than a degeneration of structures arrested in their develop- 
ment. We fail to see, however, that the death of the embryo, prior to 
the formation of the cysts, is in any way incompatible with the theory 
of Mettenheimer ; indeed, we cannot but think it extremely probable 
that in this, as in the case of fleshy moles, it is the developmental force 
diverted by the death of the embryo into an unwonted channel which 
is the great cause of the activity of the degenerative process. And, 
moreover, this is all the more likely to take the form of cystic degen- 
eration on account of the peculiar anatomical conditions under which 
the villi of the chorion, and more especially those of the placenta are 
produced. The period within which hydatidiform degeneration may 
originate does not probably extend beyond the tenth week, for it is 
during that period that the activity is greatest in the growth and 
multiplication of the villi ; and, at a later stage, when bloodvessels 
have largely occupied the bulk of the villi, it would appear that they 
are no longer capable of undergoing that form of degeneration. A 
certain dropsical condition, or secondary oedema, as Gierse describes it, 
of the membranes, is probably an essential part of the degeneration in 
question, and may serve to account for the constant supply of the fluid 
which fills the sacs. Although the special activity in the development 
of the villi which ultimately would have formed the perfect placenta, 
might naturally be expected to attract thither the morbid action, ex- 
perience has shown that this is not invariably the case. 

An important question has arisen as to whether a portion of placenta, 
retained at the full term, can take on hydatidiform change. This has 
been answered in the affirmative — among others, by Montgomery and 
Ramsbotham — but all recent writers dispute the conclusion. In the 
majority of cases, an examination conducted with every care shortly 
after expulsion fails to detect any trace whatever of the embryo, although 
in some instances a foetus has been discovered, and this is, doubtless, 
what has led to the erroneous conclusion referred to. The explanation 
of the facts as observed is to be found in the fact that, here, growth is 
limited to the chorion and the degenerated villi, and that the uterus is 
filled with an enormous mass of cysts which have sprung from this 
source, so that the cavity of the amnion and its contents are almost 
inevitably obliterated. The destruction of the embryo is, for this 
reason, much more complete than in the fleshy variety of mole. 

In regard to the symptoms of this form of mole, they are at first 
identical with the ordinary signs which are supposed, in the first three 
months, to indicate pregnancy. The usual symptoms, and more 
especially those which have their seat in the mamma, then become 
indistinct and perplexing. The patient is ill at ease, her appetite and 
digestion become impaired, and her feelings are quite different to those 
which attended former pregnancies. So soon as the degenerative 
process has been thoroughly established, the increase in the bulk of the 
uterus goes on with very unusual rapidity, and it has been noticed to 
expand irregularly, and more in a lateral than in the usual upward 
direction. When the period arrives at which the conclusive proofs of 



212 ABNORMAL DEVELOPMENT. [CHAP. 

pregnancy should, under ordinary circumstances, be distinctly mani- 
fested, the absence of foetal pulsation and ballottement may arouse 
suspicion as to the nature of the case. But at a period even earlier 
than this, watery and sanguineous discharges, mixed or separately, may 
occur, the former being due to the bursting of distended vesicles, which 
have probably been submitted to considerable pressure. It occasionally 
happens that, along with these discharges, a few vesicles only, or a 
larger proportion of the mass, escape, which at once reveals the nature 
of the case. There is, in addition, another symptom to which we would 
call special attention, and which we have found of the highest impor- 
tance in practice in the diagnosis of this affection. This consists in a 
peculiar doughy, boggy feeling, which is revealed on palpation, and 
which we take to be in the highest degree characteristic, more especially 
if we take along with it the absence of that irregular hardness which 
indicates the prominences of the foetus. The term " dense" which we 
find generally used to describe the feeling of the uterus in this condition 
is, we apprehend, singularly inappropriate. " Tense/' again would 
represent correctly enough the effect of the rapid distension ; but the 
sensation yielded by palpation, which we have had the opportunity of 
thoroughly testing in several cases, is, we are persuaded, more correctly 
described above, than by either of the terms specified. 

The existence of moles of this nature is seldom prolonged beyond the 
sixth month, when repeated haemorrhage, and over-distension of the 
uterus, entailing probably a partial separation of the placenta, will 
usually have excited uterine contraction. The effect of these con- 
tractions, when once thoroughly aroused, is to effect the complete 
separation of the entire ovum, which insures the safety of the woman 
by the arrest of the haemorrhage. It would seem, however, that under 
certain special circumstances, fortunately of rare occurrence, the con- 
nection between the uterus and the ovum is so firm that a portion only 
of the fruit of conception is expelled. "In such cases," says Scanzoni, 
" portions of the ovum remain behind in the uterine cavity for a con- 
siderable time, on account of their firmer connection with the inner wall 
of the uterus. These may give rise to profuse and long-continued 
floodings, as we have seen in one of our cases occurring in the gynaeco- 
logical clinique at Prague, where an exhausting haemorrhage, which had 
continued for some months after the expulsion of a vesicular mole, was 
first arrested on the removal by the hand of the remainder of the ovum, 
which had remained behind in the cavity of the uterus." 

What is, however, of more frequent occurrence when the whole of 
the ovum is not at once expelled, is that the case turns out to be one of 
twin pregnancy, in which the membranes of one embryo only have 
become the seat of the degeneration in question. Doubtless, under 
such circumstances, the uterus, after expelling a large hydatidiform 
mass, will not cease in its efforts until the whole of its contents have 
been expelled; but, a certain number of cases have been recorded, in 
which, after such an event, a fully developed child has been expelled 
after an interval of a few months, a fact which is only reconcilable 
with the idea above expressed. This is said by Montgomery to have 
occurred at the birth of the celebrated anatomist Beclard. The most 



XII.] DISEASES OF THE OVUM. 213 

recent observations on this subject seem to indicate that examples of 
this nature are by no means of nn frequent occurrence, which obviously 
shows that we should exercise caution in the treatment of such cases, 
lest we destroy the living germ while removing the dead. 

The treatment of all such cases will of course depend on the urgency 
of the symptoms. So long as they are moderate in severity, and are 
not such as to call for immediate action, our course of treatment must be 
purely expectant, more especially as there will almost always be an 
element of doubt in the diagnosis. But, so soon as profuse, watery, 
and hemorrhagic discharges shall indicate serious danger to the woman, 
we must not delay until interference is a mere dernier ressort, but act 
promptly, and in the manner most likely to empty the uterus speedily 
of its contents. In several cases of hydatids, we have found the ergot 
of rye act quite satisfactorily, and effect expulsion without difficulty ; 
as, indeed, it usually does when the uterus has reached a certain degree 
of distension. We recommend, therefore, that in the first instance, 
this drug should be employed; but if, as often happens, it fails to ex- 
cite uterine effort, we must then resort to other means. A sound or 
catheter has been introduced into the womb, and successfully used so 
as to break up the mass, and separate it as far as possible from its 
uterine attachments; but we regard it a safer as w T ell as a more 
satisfactory method, to dilate the os and cervix by means of Barnes's 
bags or other similar appliances, so as to introduce the hand, and 
remove at once the whole mass. The dilatation of the os and cervix by 
means of sponge-tents would also have the effect of exciting the uterus 
to contraction, and would have the further advantage of checking 
haemorrhage. Galvanism has also been recommended ; the object, of 
course, in each and all of these modes of procedure, being to empty 
the uterus safely as well as quickly. Nothing special need be said 
in reference to the treatment of the fleshy mole, as in that case the 
diagnosis is much more difficult. Although the unexpected arrest of 
development, and the general, constitutional disturbance, with the ces- 
sation of such of the signs 01 pregnancy as may previously have been 
present, may indicate the probability of this affection, it is seldom that 
its nature is recognized until the carneous mass, with the blighted 
ovum, has been expelled. 

There is yet another group of cases in which the pathological 
phenomena are also to be found in a portion of the ovum, but which 
occur at a later period of pregnancy than those which we have just 
been considering. In these instances, development goes on uninter- 
ruptedly until the placenta has been fully formed ; and it is to diseases 
of that organ that the death of the foetus is then due. Among the 
affections of the placenta which may have this result, is Apoplexy of 
the Placenta, in which blood is effused, by rupture of vessels, into the 
parenchyma of the organ, exactly as takes place in the lung, and with 
a similar result as regards the respiratory function. Another affection 
which, as we have already seen, is apt to attack the tissue of the fleshy 
mole, is Fatty Degeneration. Recent researches show that, at a more 
advanced period of gestation, the same pathological change is apt to 
invade the tissue of the placenta, and so to alter its structure as to 



214 ABNORMAL DEVELOPMENT. [CHAP. 

interfere seriously with, and ultimately to arrest, the development of 
the embryo. The cause of this fatty degeneration has been very care- 
fully investigated by Barnes, Priestly, and others; and the conclusion 
at which they seem to have arrived is, that the fatty molecules are the 
result of a low form of placentitis — being either thrown out, primarily, 
as inflammatory exudations, or formed, secondarily, of inflammatory 
products, which subsequently degenerate into fat-particles. Placentitis 
is another affection which may cause intra-uterine death — the inflam- 
matory process, in these instances, attacking the organ, and in extreme 
cases leading to hepatization, induration, abscess, and the other termi- 
nations of the inflammatory state. The morbid action is generally 
confined to a limited portion of the organ, or to a few lobules, and 
extends from the maternal towards the foetal surface of the placenta. 
There is reason to believe that morbid adhesion of the placenta may 
have its origin in placentitis ; and, in connection with it, hypertrophy 
of the decidua serotina has not unfrequently been observed. General 
oedema, or dropsy of the placenta, is another affection of the organ 
which has been carefully observed by Meckel and Gierse. The appear- 
ances are here altered to those which are characteristic of oedema in all 
soft tissues; swelling, paleness in color, and serous infiltration, being 
the leading features which an examination of the tissue reveals. "This 
must not/ 7 as Simpson well remarks, " be confounded with the white, 
blanched, and merely anaemic state of the placenta, often observable 
in cases where the child has died of peritonitis, or other foetal diseases, 
and been retained in utero for some time subsequently ; and it is patho- 
logically very different also from the stearoid or fatty degeneration." 

Hypertrophy of the placenta, cartilaginous and calcareous degenera- 
tion, ramollissement, and atrophy, are all affections which have been 
specially observed. In many of the affections above enumerated, there 
seems to be a tendency to return in subsequent pregnancies ; and it may 
be held as an established fact, that such has been the case in many of 
those instances of repeated abortion which cause so much disappoint- 
ment to the mother. Under the influence of these degenerations, the 
nutrition of the placenta may, for a time, go on uninterruptedly. Soon, 
however, its function is interfered with, and the safety of the foetus 
becomes compromised. The general rule, in such circumstances, un- 
doubtedly is, that the uterus is excited by the foreign body to active 
contraction, and abortion is the result. But, in a certain number of 
instances, the decreased vitality of the placenta is maintained, while the 
embryo becomes shrivelled and attenuated to an extraordinary degree, — 
under which conditions it may be retained until the full term of 
gestation is reached, and then discharged. This latter result is more 
likely to occur in twin than in single pregnancies — the placenta of the 
one foetus being diseased, and the other, remaining healthy; and it is 
probably under such circumstances that with a fully-formed child, a 
shrunken foetus is sometimes expelled — giving rise, erroneously, to a 
suspicion of super foetation. The dead foetus, in these instances, is 
generally flattened by the pressure which is exercised upon it by the 
other in the course of its development. 

An extremely rare and curious phenomenon has been occasionally 



XII.] DISEASES OF THE FCETUS. 215 

observed, in which, the foetus remaining in utero, labor does not come 
on at the usual time; and the remains of the foetus may be retained for 
a considerable period, or discharged piecemeal by the vagina, without, 
for a time, at least, seriously affecting the health of the mother. This 
has been called Missed Labor, and is alluded to by Dr. Tyler Smith in 
his admirable Manual, in which he gives the history and illustration 
of a case which occurred in the experience of Dr. Oldham. 

The Umbilical Cord may also, like the placenta, be the seat of certain 
anomalies, or morbid affections, which may cause the untimely death of 
the foetus. Under the former class, may be ranged cases of true knots 
on the cord, and twisting of it round various parts of the child, which 
may possibly be attended with fatal results; and, under the latter, may 
be mentioned inflammation of the cord, or of any of its parts, and 
cystic degeneration, which was first described by Ruysch, and has been 
mentioned by subsequent writers, although it is probably of very rare 
occurrence. 

Diseases of the Foetus. — Having now considered the chief morbid 
conditions which affect the various parts of the ovum, including the 
placenta, we may at this place advert, with propriety, to certain diseases 
to which the foetus itself is liable. With few exceptions, the foetus may 
be said to be subject to the same diseases as are observed after birth. 
Among the most frequent are the affections of the nervous system which 
give rise to haemorrhages ; or which consist primarily in inflammatory 
affections, from which spring secondary effects, attended with very 
serious results to the mother as well as to the child. Haemorrhages 
into the substance of the foetal brain are very rare; but it is not so 
much so in regard to discharges which take place behind the membranes 
or on the surface of the brain. These affections when observed, and 
when unconnected with obstructed delivery, have usually been found 
associated with placental apoplexy or obstruction of the cord. Of all 
the results of inflammatory action in this situation, the most familiar is 
chronic hydrocephalus, in which the quantity of serum effused within 
the cranium is often so great as not only to cause a certain amount of 
atrophy of the encephalon, but also an increase in the size of the head, 
so considerable as to form a serious obstacle to delivery. Convulsions 
may attack the foetus while it is yet in the womb, and cases have been 
observed in which convulsions on the part of the mother were com- 
municated to the child. The probable cause of these, in most instances, 
is arrest of the circulation, which causes the foetus to die of apnoea, — of 
which convulsive action is a frequent symptom. Although the lungs 
are as yet of very small size, it would appear that they are occasion- 
ally, though very rarely, the seat of inflammation ; but pleurisy and 
tuberculosis are of much more frequent occurrence than pneumonia. 
Acute and chronic peritonitis, whether general or partial in extent, is 
met with much oftener than the above. This affection may be accom- 
panied with effusions, which are identical in appearance and general 
characteristics with those which are so frequently observed after birth ; 
and, according to the type of the inflammatory action, they may take 
the form, either of coagulable lymph, by means of which the viscera 
may be glued together, or of a fluid effusion, the quantity of which 



216 ABNORMAL DEVELOPMENT. [CHAP. 

may become enormous, and may cause the death of the foetus either 
before or after birth, or may even render delivery difficult. It would 
appear from certain researches made by Simpson in reference to this 
affection, that it is not unfrequently associated with syphilitic disease 
of the mother. Diseases of the liver and of the spleen, many of them 
associated with the same constitutional disorder, have also been fre- 
quently observed ; and, more rarely, affections of the alimentary canal, 
with which may be classed cases of Ascarides and Taenia, these entozoa 
having been repeatedly found in the intestines of the unborn. Conges- 
tion, cystic degeneration, and other affections of the kidney, as well as 
various affections of the ureter, have occasionally been noticed ; and 
the same may be said with reference to cardiac diseases, examples of 
which, including peri- and endocarditis, have also been noted. Va- 
rious diseases of the skin are observed in children born either prema- 
turely or at the full time, including the characteristic eruption of certain 
febrile diseases, such as variola, which may be contracted from the 
mother within the uterus ; or, what is much more wonderful, which 
may be communicated through the mother to the child, she herself 
remaining unaffected. Erythema, pemphigus, and other forms of skin 
disease, are very frequently to be received as evidence of the existence 
of syphilitic disease, in one parent or in both. 

Fracture of the bones of the foetus is an affection which is usually 
the result of violence from without; but a sufficient number of cases 
have been observed to establish the fact that, independently of any 
such accident, intra-uterine fracture may occur. Some of the recorded 
instances of this are of the most extraordinary nature. Chaussier, for 
example, tells us of one case in which there were forty-three, and 
another in which there were no fewer than one hundred and thirteen 
fractures of the bones of the foetus, facts which it is difficult to conceive, 
unless under the supposition that extensive disease of the bones existed. 
But, a more extraordinary phenomenon still is the occurrence within 
the womb of what has been described as spontaneous amputation. 
Haller, and many physiologists after him, supposed that these were 
cases of simple arrested development, but that this cannot be the case 
in every instance is proved by the discovery within the uterus of the 
missing part. The fact of this spontaneous amputation having, at a 
more advanced period, been clearly established by irrefragable evidence, 
the question which next presented itself for solution was the manner in 
which such a separation within the uterus could by any possibility take 
place. To this, the reply given by Chaussier, Billard, and other writers 
of that period, was that the only manner in which it could be accounted 
for was to suppose that the parts separated had been the seat of gan- 
grene, and that spontaneous amputation had taken place at the line of 
demarcation between the living and dead issue. The discovery in 
several cases of the amputated part, which had not undergone any 
decomposition, soon proved that this theory was quite erroneous, and it 
is to Montgomery that we owe what is now generally believed to be the 
correct explanation of what was long a pathological problem. Mont- 
gomery's view, which has, since he wrote, received the most ample 
confirmation, was that the intra-uterine section was effected, either 



XII.] INTRA-UTERINE AMPUTATION. 217 

by constriction exercised by the cord, or by special bands consisting 
originally of organized lymph, such as is usually elaborated under the 
influence of inflammatory action. These bands or threads having be- 
come fixed round a limb, their compressive power becomes daily 
augmented, on the one hand, by their own contractions, and, on the 
other, by the growth of the body within their grasp. In the majority 
of cases, the complete separation of the limb is not effected, and it is 
only partially divided. But if the processes of contraction and growth 
continue, the supply of blood to the distal part of the limb is first 
diminished and then cut off; and, ultimately, the nutrition of the bone 
being similarly interfered with, it becomes brittle, and probably breaks 
off short at the point of constriction. A most interesting observation, 
which we owe to Simpson, in connection with this subject, is the occur- 
rence in these instances of an attempt on the part of nature to remedy 
the deficiency by a process of reproduction which is familiar low in the 
animal scale, but of which, as we ascend, nature avails herself less and 
less. When, in a case of this kind, as he shows by reference to a con- 
siderable number of cases, separation in utero occurs, a stump is found 
which offers certain peculiarities in appearance. " Two points of the 
skin, or rather of the subcutaneous tissue, are found adherent to the 
ends of the ulna and radius, and present a depressed or umbi Heated, 
form, particularly when the forearm is flexed and moved, and the 
fissures of the skin run in converging lines to these two points as 
centres. Midway, and a little in front of these two points, the rudi- 
ment of the regenerated extremity is situated in the form of a raised 
cutaneous fold, or fleshy mass, or tubercle, and having on its surface 
one, two, or more smaller projections or nodules, furnished with minute 
nails." In illustration of this, the appended engraving is given, repre- 
senting the stump of the left 1 forearm of a foetus of -the seventh month, 
preserved in the Obstetric Mu- 
seum of the University of Ed in- fig. 94. 
burgh. There are five small 
rudimentary fingers tipped with 
minute nails, in the usual posi- 
tion on the end of the stump. 

Deviations from the ordinary 
process of development fre- 
quently give rise to results 
which constitute Monstrosities. 
The subject of monsters, how- * / 

ever, although it might fairly / 

enough be discussed here, is 

One Of SUch magnitude that We Intrauterine amputation and attempted 

must needs pass it by, as it is reproduction. 

quite impossible to give to it 

even the briefest notice in a work such as this. Those who would pursue 
the subject may refer to the magnificent Traite de Teratologic by Geof- 
frey Saint-Hilaire, and to other works where the subject is fully and 

1 It is somewhat remarkable that this accident generally occurs on the left side. 




218 DISEASES OF PREGNANCY. [CHAP. 

exhaustively treated. The Anencephalic, Cyclocephalic, and other 
varieties, which consist in the absence of portions of the cranium and 
subjacent parts, are interesting chiefly, from a purely practical point of 
view, as being likely to puzzle any one who, on making a digital ex- 
amination during labor, might chance to touch such a formation. 
While the double monsters are, as we shall see, interesting in their 
practical bearing, as being certain to be attended with difficult labor, 
the whole subject of monstrosities and malformations is, however, here 
quite beyond our grasp. 



CHAPTER XIII. 

DISEASES OF PREGNANCY. 

I. DISORDERS OF THE DIGESTIVE FUNCTIONS — EXCESSIVE VOMITING : TREATMENT 
OF: QUESTION OF INDUCTION OF PREMATURE LABOR IN — ANOREXIA — GASTRO- 
DYNIA — PYROSIS— CONSTIPATION — DIARRHCEA. II. DISORDERS OF RESPIRATION 
— DYSPNOEA — COUGH. III. DISORDERS OF THE CIRCULATION — CONDITION OF 
THE BLOOD IN PREGNANCY: DIMINUTION OF BLOOD-CORPUSCLES: PROPOR- 
TIONAL ALTERATION IN FIBRIN AND ALBUMEN — SUPPOSED RESEMBLANCE OF 
THE PHENOMENA OF PREGNANCY TO THOSE OF CHLOROSIS — ADMINISTRATION 
OF IRON IN PREGNANCY — PLETHORA — VARICOSE VEINS — HAEMORRHOIDS — 
THROMBUS OF THE VAGINA. 

Many of the symptoms which have already been detailed as indi- 
cative of pregnancy are such as, under ordinary circumstances, would 
be regarded as pathological phenomena, and would be classed as Dis- 
eases, or at least as Disorders. But, under the special circumstances 
attending the pregnant state, which implies the development of a 
function purely physiological, these symptoms, which are in a great 
measure the result of sympathetic or reflex irritation, are naturally 
looked upon as physiological indications of a natural process. So 
long, at least, as they are confined within moderate limits, it is usual 
either to treat them by means of mild palliative measures, or to disre- 
gard them altogether, provided the general health does not seem to be 
in any serious degree affected. A very small amount of practical 
experience suffices to show that great differences exist, consistently with 
a perfectly healthy pregnancy, in the gravity of the symptoms which 
are manifested; a woman, in one case, being scarcely exposed, during 
the whole period of her pregnancy, even to discomfort; while, in 
another, with an equally happy result, disagreeable symptoms of one 
kind or another have been well-nigh incessant. The difficulty, there- 
fore, is where to draw the line, and to determine what cases demand 
treatment, and in what others interference is to be avoided. These 
remarks apply especially to the abnormal digestive phenomena which 
so invariably attend pregnancy, and to certain other symptoms which 
may be referred to the same category. There are, as is well known, 
many other symptoms, which are exceptionally attendant on gestation, 



XIII.] DIGESTIVE DISORDERS. 219 

and which, when present, are essentially pathological from the first. 
The whole subject, therefore, of the diseases of pregnancy, is one to 
which careful attention should be given ; by the student, in the first 
instance, that he may be able to appreciate the significance of the 
symptoms which he may observe; and, by the practitioner, that he 
may be able, in case of need, so to manage a pregnancy with prudence, 
as to avert such dangers as may be foreseen and avoided. There is 
good reason to believe that a sound knowledge of the morbid phenom- 
ena of pregnancy may enable us not only to avert dangers the nature 
of which is now well understood, but to discover, in the future, means 
whereby the dangers and diseases of development may be combated, by 
agents not yet at our command, and the risks of childbed be thus 
lessened both to mother and child. 

A study, however superficial, of diseases of the womb, or of menstrual 
derangements shows clearly that a sympathy, of a very intimate kind, 
exists between the uterus and the nervous and digestive systems; a 
sympathy which a knowledge of the origin and distribution of the par 
vagum and sympathetic nerves might already have led us to expect. 
We cannot wonder, then, that, during pregnancy, when the function 
of the uterus is so exalted, this sympathetic action should also be ex- 
aggerated. The symptoms manifested are infinite in their variety, 
according to the constitution of the individual ; but so deceptive and 
erratic are they in their mode of development, that we can place no 
dependence on them as a guide to the probable progress of a given case. 
There are instances, and these by no means unfrequent, in which the 
constitution is actually improved by the occurrence of pregnancy ; and 
cases are even observed in which the downward course of lingering and 
wasting disease is arrested by conception, and is held in abeyance during 
its continuance. There are, on the other hand, extreme cases, in which 
the life of the woman is actually in danger, not from any acute or 
organic disease, but from the great functional disturbance which, in 
these peculiar instances, pregnancy provokes. The time at which such 
symptoms as merit the name of pathological phenomena manifest them- 
selves varies very considerably. Some have their origin in the early 
months, and such will usually be found, on careful examination, to be 
purely sympathetic; while those, on the other hand, which do not call 
for attention and treatment till towards the end of the term of gesta- 
tion, will be found, as a rule, to be due to some pressure, or mechanical 
interference with the functions which are disturbed. 

Most modern writers, in considering systematically the disorders of 
the pregnant state, have adopted either the classification of Desormeaux, 
or some modification of it. Following their example, we propose to 
divide the affections in question into the following groups : 

1. Disorders of the Digestive Functions. 

2. Disorders of Respiration. 

3. Disorders of the Circulatory System. 

4. Disorders of the Secretions and Excretions. 

5. Disorders affecting Locomotion. 

6. Disorders affecting the Nervous System. 

7. Displacements of the Gravid Uterus. 



220 DISEASES OF PREGNANCY. [CHAP. 

I. Disorders of the Digestive Functions. — Vomiting, or rather " morn- 
ing sickness/' is, as has already been stated, one of the most constant, 
as it is one of the earliest of the signs of pregnancy. Indeed, it may 
be said that, owing to the intimate sympathy which has been spoken 
of as existing between the uterus on the one hand, and the stomach on 
the other, almost all pregnant women are affected with it more or less. 
Sometimes, this symptom manifests itself almost immediately after con- 
ception, — almost always in the course of a few weeks, — and it generally 
continues till the period of quickening has been reached. So long as 
the vomiting is moderate, it is best not to interfere ; and, indeed, an 
impression very generally prevails, to which Puzos and others have 
given expression, that it is a salutary symptom, and midwives have an 
aphorism that "a sick pregnancy is a safe one." But in some cases, 
the sickness goes to a very great extent, the woman being constantly 
nauseated, and the stomach rejecting almost everything, solid or fluid, 
which it receives. In some of the worst of these cases, it is a matter 
of constant astonishment how it is possible for the vital powers to be 
sustained, as everything seems to be ejected almost as -soon as it is 
swallowed. Of course, in all such, a certain portion of the food must 
be retained ; or the stomach rapidly absorbs a portion before its con- 
tents are voided. As a rule, the symptom is most violent, and most 
frequently calls for treatment in the case of primiparse ; but it occa- 
sionally happens that a woman, who has previously been pregnant 
without any very marked digestive disorder, may, on a subsequent 
occasion, undergo the misery of this affection to the fullest extent. 
There exists, moreover, a great variety in the amount of pain or dis- 
comfort to which the act of vomiting gives rise, — some women simply 
emptying the stomach, without pain or effort, as in the vomiting which 
is symptomatic of brain disease, while others suffer pain and exhaustion 
from the excessive retching, to an extent which leads us to marvel how 
it is possible, under such continued spasmodic action, for the uterus to 
remain quiescent, and to retain its contents. Even in the extreme 
cases, the emaciation is by no means in proportion to the severity of 
the symptoms, and the development of the fetus goes on as steadily as 
if the system were quite unaffected by any disturbing influence. 

In the cases which are most intractable, the matters ejected are often 
mixed with bile, the breath is fetid, and the patient complains of severe 
epigastric pain. The latter has been relieved by the application of a 
small blister to the epigastrium, which may be dressed with morphia. 
The experience of all, however, who have tried opiates seems to be 
against their use at least by the mouth. Sometimes, quite suddenly, 
and without any treatment whatever, the symptoms cease, after having 
attained their maximum of intensity; but in other cases they persist, 
and, if not relieved, reduce the woman to the last stage of exhaustion, 
when nature at last interferes for her relief by the occurrence of spon- 
taneous abortion, — a fact which has been generally received as an indi- 
cation of the treatment which we should adopt in extreme cases. There 
is scarcely any form of rational treatment which has not been tried, 
with a view to the alleviation of this distressing symptom. We shall 
only mention here, however, such remedies as have been commended 






XIII.] TREATMENT OF VOMITING. 221 

by the best authorities, or have seemed to us to be the most reliable. 
Narcotics, as a rule, are worse than useless. When the symptoms are 
slight, and confined to a simple aggravation of the ordinary morning 
sickness, — under which some women are vastly more impatient than 
others, — the remedies employed should be of the mildest possible nature, 
and in many cases some bitter infusion, or a cup of strong tea before 
rising in the morning has quite a decided effect. In several instances, 
we have known the nausea to be greatly relieved, and the vomiting 
entirely checked by breakfasting in bed, and not rising for some little 
time afterwards. In some, food is only retained w T hen cold ; and in 
others, nothing will lie on the stomach but what is hot. Ice will some- 
times check it; and bismuth, in doses of eight or ten grains, has been 
said by Cazeaux to have a good effect. It will be obvious from these 
facts that the management of the diet is an important part of treatment, 
but One which will often perplex us sadly. 

The strictest attention must be paid to the state of the bowels, and 
marked benefit is often derived, in cases where they are sluggish in 
their action, from a gentle dose of some such mild laxative as Carls- 
bad salts, Pulna water, or the phosphate of soda. There is, perhaps, 
no class of remedies which is attended with such beneficial results as 
effervescing draughts, among the best of which may be mentioned the 
granular effervescing citrate of magnesia. On the Continent a favorite 
remedy is the "potion de Riviere," which is prepared and given in the 
following manner, so that the effervescence actually occurs within the 
stomach : 

R. 1. Acid. Citric, gr. xxxvj. 
Syr. Simp., ^j. 
Aquae, t ^ij. S. 

2. Potass. Bicarb., gr. xxxvj. 

Aquas, ^iij. S. 

Sig. A tablespoonful of each to be taken successively. 

Calumba and soda is a favorite combination with some; and hydro- 
cyanic acid, or creasote, may be tried, although their usual effect is not 
to be depended upon. Salicin has also been mentioned : and the salts 
of cerium have been used and strongly recommended by Simpson, but 
in so far as our experience goes, with no better effect than the other 
means which have been mentioned. Should there be much exhaustion 
of the patient's strength, stimulants must be employed; and, indeed, 
these, when taken in moderate quantities, and in an effervescing form, 
such as champagne, or brandy and soda-water, seem almost to exercise 
a specific influence. In some cases, pepsin is a very valuable addition 
to other modes of treatment. Sometimes, when such of the above 
measures as may have been selected are totally devoid of effect, we 
stumble fortunately on some agent which may chance to have the de- 
sired effect, even though it be of the simplest possible character. Of 
such a nature is milk and lime-water, and barley-water; indeed, in 
reference to the latter, we have seen such striking instances of its 
efficacy, in which it has been retained by the stomach when all else 
has been rejected, that we have come to look upon it as among the 
most valuable agents which we have at command. Lumbar pain is 



222 DISEASES OF PREGNANCY. [CHAP. 

sometimes associated with the vomiting of pregnancy, and it is possible 
that this may depend upon that slight form of uterine inflammation to 
which Burns refers as a cause of obstinate vomiting. This affords, at 
least, a rational explanation of the effect of fomentations, hot baths, 
and if the patient be plethoric, of leeches applied to the loins, in arrest- 
ing the vomiting in this class of cases. A beneficial effect is also de- 
rived from the use of belladonna, applied either to the abdomen, as 
recommended by Bretonneau, or administered in the form of pessaries. 
In some cases, where the irritability of the stomach seems merely to 
be increased by food and drink, it will be proper for us to sustain the 
powers of nature by nutritive enemata ; and, availing ourselves, 
further, of the possibility of ingestion by the skin, we may give warm, 
baths, to which gelatinous matter, in any form, may be added ; or 
inunction, by means of cod liver, or other oil, may be practiced. 

But, failing all other means, the question remains for solution, 
whether we are warranted in imitating what nature occasionally effects 
by her own efforts, by inducing the premature expulsion of the fcetus. 
We shall not pause here to consider, as some have done at great length, 
the moral aspects of this important practical question. The idea in- 
volved is death to the foetus, in order either to avoid risk to the mother, 
or to save her life, when that is in immediate and urgent danger; and 
no right-minded man can decide in such a case, without feeling that a 
grave moral responsibility rests upon his decision. We apprehend 
that when it is a mere question of freeing the woman from the risk of 
a contingent, though not imminent danger, we are in no case warranted 
in sacrificing the life of the child, and we must therefore dissent from 
the conclusions of those who would sanction such a proceeding in any 
condition of the mother short of extreme peril. The conclusion at 
which Cazeaux and others have arrived is, that under no circumstances 
are we justified in inducing premature labor for the relief of the vom- 
iting of pregnancy; but to this we cannot assent, although we admit 
that the cases which would warrant the operation are of extremely rare 
occurrence. That such cases do occur we cannot doubt ; but let the 
young practitioner be assured that a lifelong experience will scarcely 
bring such a case under his observation, and let him beware, therefore, 
lest, by exaggerating to himself the importance of the symptoms, he 
may, in his anxiety, be led into error. For his guidance, we would 
call attention to the following facts : 

1. Cases have been recorded in which death has undoubtedly been 
the result, during pregnancy, of vomiting, and of the inanition conse- 
quent upon it. Two examples of this are narrated by M. Dance, in 
the Archives Generates for 1827, where the vomiting began with preg- 
nancy and terminated fatally, — in the one case at three, and in the 
other at three and a half months. Dubois met with twenty fatal in- 
stances in thirteen years, and Tyler Smith alludes to two cases "in 
which the induction of premature labor artificially was so long delayed 
that the patient died before abortion could be induced." Burns, on 
the other hand, says that " he has never known vomiting, purely de- 
pendent on pregnancy, end fatally;" and a similar observation is made 
by Desormeaux. 



XIII.] ANOREXIA. 223 

2. Numerous cases are recorded in which the operation was success- 
fully performed, with immediate relief of the symptoms. Such in- 
stances, however, while they afford proof of the safety of the operation, 
are not to be admitted as, in any sense, arguments in favor of the prac- 
tice ; moreover, the result alluded to is far from being invariable. 

3. Instances have occurred, in the experience of almost every prac- 
titioner, in which the symptoms, although of great severity, spontane- 
ously ceased, and the labor reached a happy termination ; and not 
a few are recorded, on excellent authority, which show that, at the 
last moment, and in the most desperate case, the vomiting may cease, 
and an equally satisfactory result ensue. In illustration of this, 
we may cite the following example, which occurred in the practice of 
Dubois : 

"A young German lady, two and a half months pregnant, had vomited almost 
incessantly from the first fortnight of her pregnancy. For six weeks she vomited 
every few minutes, and the smallest spoonful of fluid set up at once the most 
energetic contractions of the stomach. She was excessively emaciated and feeble: 
her breath was very fetid. In a word, the symptoms were so grave that M. 
Dubois called in Chomel. The prognosis of both was almost hopeless, and they 
left the lady, in the belief that she had but a few days to live. Two days after 
the consultation, the patient was seized with severe diarrhoea, and from that 
moment the vomiting ceased, and never returned. She could then take and retain 
some nourishment, the quantity of which was gradually increased until she re- 
gained her strength and full digestive powers." 

This woman, then, after being so near death that two such men 
considered it a hopeless case, made a perfect recovery, and carried her 
child to the full term. Dubois gives quite frankly, the details of 
tw r o similar cases, in which he proposed abortion. In both the women 
refused and went to the full term. 

A review of facts such as these should certainly lead us to use the 
greatest possible caution, when the question of premature labor comes, 
in such cases, under our consideration. It is unfortunate that the 
great majority occur in the early months of pregnancy, — a fact which 
increases our responsibility. For, if it were essentially a disease of the 
last, instead of the first weeks, we might provoke labor with less 
hesitation, as we would then have a viable child, instead of an embryo 
whose expulsion involves its death. The special circumstances which 
attend each case should be taken anxiously into consideration, and our 
verdict must depend mainly upon these, but in full view of the expe- 
rience of the past. 

Among the other disorders of digestion to which pregnancy gives 
rise, Anorexia is sometimes prominent. The lack of appetite, amounting 
occasionally to actual disgust and loathing, is most marked in the 
early months, although not confined to that period. It is to be met by 
very careful attention to the normal functions, and by regulation of diet. 
The effect of tonics, although occasionally good, is not to be depended 
on ; and it must always be remembered, in reference to the treatment 
of this and other disorders of the same class, that although we may 
mitigate symptoms and deaden sensibility within certain limits, w r e 
cannot annihilate the sympathy upon which the manifestation of these 
phenomena depends. It is far from unusual for the appetite to become 



224 DISEASES OF PREGNANCY. [CHAP. 

depraved in a manner similar to what occurs in chlorosis ; and this, in 
an aggravated form, constitutes the affection known as Pica. What 
usually occurs in healthy pregnancy is, that the appetite is altered but 
not depraved, milk, fresh fruits, succulent vegetables, and other articles 
of diet easy of digestion being the form of " longing" which prevails. 
But when this takes a morbid direction, we find the desire for such 
substances replaced by a craving for raw rice, soap, chalk, cinders, slate 
pencil, and even substances more disgusting. If the morbid longing be 
for such matters as may be prejudicial to health, they must of course be 
withheld, even by forcible means should this be necessary. It is, how- 
ever, usual and is certainly judicious, to humor the tastes as far as is 
possible, as they not unfrequently point to the class of diet which agrees 
best with the patient. 

Gastrodynia and Pyrosis, if present in any marked degree, must be 
treated by precisely the same means which we would adopt in the same 
affection occurring in other circumstances; and for this purpose bismuth, 
calumba, and antispasmodics, combined if necessary with minute doses 
of opium, may be prescribed. In heartburn and acidity, Dinneford's or 
Hendry's fluid magnesia, or the effervescing citrate or bicarbonate of 
potash, may be- administered in each case with every prospect of at 
least temporary relief to the symptoms. Constipation is a very frequent 
concomitant of pregnancy, and is due to the pressure which is exercised 
by the pregnant womb upon the bowels, thus not only reducing its 
calibre, but also paralyzing to some extent its muscular fibres. In other 
cases, there is a want of bile, and they who hold that there is dur- 
ing pregnancy a pseudo-ana?mic state of the system, attribute the 
irregularity of the bowels to the same causes which operate in the early 
stage of chlorosis. In any case, whatever the cause may be, constipation 
is of constant occurrence, and women who were not previously of a 
costive habit frequently require laxatives during the whole course of 
their pregnancy. If clay-colored stools indicate that the function of 
the liver is interfered with, a few grains of blue pill given occasionally 
will often do much good. In the opposite condition of diarrhoea, which 
is by no means unfrequent, we must be careful to discriminate the na- 
ture of the case before pushing astringent treatment too far. If it de- 
pends upon fecal accumulation, or upon the presence of irritating matter 
in the alimentary canal, the first step in the treatment must be to clear 
out the bowels by castor oil, and then to exhibit, if necessary, such 
astringents as the nature of the case seems to call for. 

II. The Disorders of Respiration, which accompany pregnancy, are 
by no means numerous. Dyspnoea is an affection which is very common 
in the later months, and is then due to the mechanical pressure exer- 
cised in the direction of the diaphragm by the expanding womb. Pest, 
careful attention to the digestive functions, and such arrangement of 
the dress as may tend to encourage thoracic, and relieve diaphragmatic 
respiration, are the obvious and sole means by which this affection is 
to be combated. In the last weeks, the falling down of the womb 
which then occurs, will generally be found, by relieving the diaphragm 
from pressure, to put an end completely to the discomfort from which 
the patient suffers. Dyspnoea may, however, exist at any period of 






XIII.] DISORDERS OF RESPIRATION. 225 

pregnancy ; and, when it occurs in the earlier months, it is probably 
due to sympathetic irritation communicated through the nerves. We 
have known the dyspnoea under these circumstances to be very harass- 
ing, and in one instance it was accompanied during the first five months 
with severe spasmodic asthma in the case of a lady who never suffered 
from that affection either before or since. Antispasmodics are obviously 
indicated in such a case, and, in the instance in question, great benefit 
was derived from a combination of chloroform with bromide of potas- 
sium. Cough, the result apparently of mere sympathetic irritation, is 
also an accompaniment of pregnancy in no small number of cases. It 
may be found to be associated with congestion of the base of the lungs, 
or with some more serious affection of these organs. As a rule, it 
exists independently of any ascertainable pulmonary disorder, but is, 
nevertheless, frequently spasmodic, and at times so violent as to re- 
semble hooping-cough ; and in these cases it may induce abortion. 
Some combination of sedatives and antispasmodics would be the best 
form of treatment for such a case — the symptoms of which are often 
specially troublesome during the night — and by promoting sleep, may 
prevent exhaustion and constitutional disturbance. 

III. Disorders of the Circulatory System. — Careful analyses have been 
performed in order to determine the condition of the blood during the 
pregnant state. Among these, the researches of MM. Anclral and 
Gavarret are conspicuous for the care with which they were conducted, 
and the interest which attaches to the results they disclose. They 
showed clearly that the plethoric condition of the circulation, which 
had been believed in by past generations of practitioners (and which 
was often treated by the ever-ready lancet), did not exist; and not 
only this, but that the condition which was to be observed in the greater 
proportion of cases was more of an anaemia than a plethora. The fact 
is that, as a rule, an examination of the blood of a woman who is 
pregnant discloses alterations in the relative proportion of its con- 
stituents, which are closely analogous to what we may observe in 
ansemia from any cause. In the earlier months of pregnancy, it would 
appear that the blood deviates little from the normal standard, that the 
corpuscles are present in their usual number, and that the fibrin and 
albumen are scarcely altered in the proportion which they bear to the 
other constituents, the former being, if anything, rather diminished. 
In the later months, however, the blood is characterized by a remarkable 
diminution in the number of corpuscles, and a considerable increase in 
fibrin, while the proportion of albumen suffers no marked disturbance, 
what little change there is being, however, a diminution. An estimate 
has been made by the same observers, according to which they assume, 
that if w 7 e suppose the average number of corpuscles in the blood of 
healthy women who are not pregnant to be represented by the number 
125, the average in women towards the end of pregnancy is probably 
not more than 115. If, in like manner, we take 300 as representing 
the physiological average of the fibrin, the proportion of that constituent 
up till about the sixth month may be set down at 250, while from this 
period onwards, during the last three months of gestation, it steadily 

15 



226 DISEASES OF PREGNANCY. [CHAP. 

increases in quantity, and reaches as high in extreme cases as 480. 
These physiological phenomena accord perfectly with the small clot 
and bivffy coat which has been so generally observed while practicing 
venesection in the course of a pregnancy. The interpretation however, 
which was formerly attached to this, was that the appearance was due 
to an inflammatory condition of the blood, and was consequently 
evidence that the practice which was being adopted was rational and 
judicious ; but now, a more correct knowledge of true physiological 
principles enables us to recognize that such an appearance is quite 
compatible with the alterations which have been mentioned. In 
addition to the facts above noted as the result of analytical research, it 
has been further established more recently that the quantity of iron, as 
we would naturally expect from the loss of red corpuscles, is decidedly 
diminished. 

Many of the symptoms of pregnancy, it must be admitted — such as 
somnolence, weight in the head, flushing, ringing in the ears, and 
vertigo — bear a striking resemblance to those which indicate plethora. 
As the lancet has, however, in this country fallen into disuse, it is 
unnecessary to repeat that such- symptoms are no indication whatever 
of bleeding. There is, indeed, much reason to believe that the errors 
of a former generation have in this, as in some other respects, led to 
the absolute rejection of what is a powerful agent in the treatment of 
disease, and that in avoiding one extreme we have gone to the other. 
We cannot doubt, however, that in the treatment of the pregnant state 
the change has had a beneficial result, for with the blood in such a 
state as it is now demonstrated to be in the later months of pregnancy, 
no one, even in former times, would have thought of bleeding in an 
ordinary case of gestation. The analogy between pregnancy and 
chlorosis is most elaborately argued and worked out by Cazeaux, who 
goes so far as to assume that the system during pregnancy is in a state 
closely resembling amemio-chlorosis, and that the treatment of preg- 
nancy should in a great measure be based on a knowledge of this fact. 
"An animal diet," he says, " and the administration of chalybeates 
have for many years seemed to me to be as useful against the functional 
disorders of pregnancy as against those of chlorosis." 

We cannot, we confess, bring ourselves to admit, as Cazeaux seems 
to do, that an affection identical with chlorosis is a usual and normal 
condition of pregnancy. To do so would be to admit that a pathological 
state is the normal accompaniment of a physiological function, a view 
which we are certainly not prepared to accept. That the phenomena 
are so far identical has been proved, but there are other explanations 
which may be offered, more in accordance with such analogies as may 
be drawn from known physiological and pathological laws. We may, 
for example, accept it at least as possible that the demand which is, 
under the circumstances of pregnancy, made upon the mother to sup- 
ply the material necessary for the rapid development of the infant 
which she carries, may of itself cause what we are accustomed to con- 
sider a deterioration in the constitution of the blood. And yet this 
so-called deterioration may, for aught we know, be a wise provision of 



XIII.] CONDITION OF THE BLOOD. 227 

nature against the time when this demand shall suddenly cease. In- 
deed, although we have little fancy for theories in support of which we 
have no facts to advance, we do think that it is by no means improba- 
ble that the vital engine is, for a special purpose, worked at a low 
power during the last months of pregnancy. In this way at least, the 
tendency to post-partum inflammatory action may be diminished, as it 
is only by degrees, after labor, that the blood regains its normal and 
healthy composition. Or, again, this pseudo-chl orotic state may be in 
a great measure induced by inadequate nourishment, the result of the 
nausea and anorexia which so frequently occur. But, whatever the 
cause of the alteration of the blood may be, it is very doubtful whether 
iron can with propriety be administered in most cases of pregnancy. 
In certain cases in which special circumstances have induced us to pre- 
scribe it, we have found that its effect was less satisfactory than usual; 
and that it did not allay digestive disorders, but rather, from its ten- 
dency to increase the sluggish action of the bow T els — which is so fre- 
quently a complication of pregnancy — seemed, in some cases at least, 
to aggravate them. 

In thus opposing the view that pregnancy should be treated as a 
disease, when it presents what we recognize as its normal condition, we 
must guard ourselves from the possibility of misconception. There are 
cases, undoubtedly, in which the symptoms are such that we are bound 
to look upon them as cases of chlorosis ; nay, we may go further, and 
admit that such cases are by no means of very rare occurrence. Cir- 
cumstances render it highly probable that many of the signs of preg- 
nancy are intimately associated with the diminution of the blood-cor- 
puscles already alluded to, but it seems somewhat curious that these 
symptoms are often present during pregnancy, while the healthy ruddy 
complexion of the patient discourages the idea of chlorosis. In ac- 
counting for this, we must bear in mind, as Scanzoni observes, " that 
there is a form of chlorosis in nOn-pregnant women, in which the 
patients, in spite of the fact that the relative quantity of blood-corpus- 
cles has undergone diminution, preserve a quite healthy color, so that 
it is conceivable that, in pregnant women also, the pale color of the, 
general surface is no pathognomonic sign of a diminution of the blood- 
corpuscles." To this we would only add, that it consists with the ex- 
perience of all that pallor is quite as frequent in the early as in the 
late months of pregnancy, although in the former case the alteration 
in the relative proportion of the blood-corpuscles is as yet scarcely if 
at all disturbed. 

In a certain number of instances, however, the deterioration of the 
blood takes place at an unusually early period, and, running its course 
with great rapidity, leaves the woman, before many weeks have passed, 
in a state in which all the symptoms of chlorosis in its higher grade 
may be manifested; and those symptoms are all the more marked 
when the chlorosis has preceded conception. In all such cases, the 
course of gestation is more or less disturbed by the characteristic 
symptoms of the disease, and an influence is not unfrequently exercised 
upon the duration of pregnancy by the occurrence of exceptionally 



228 DISEASES OF PREGNANCY. [CHAP. 

violent symptoms, which may give rise to premature delivery. The 
experience of those who have devoted most attention to this subject 
seems to show that no hurtful influence is exercised by chlorosis in the 
progress of labor, but that a common result is that convalescence is 
greatly protracted, and that there exists an increased tendency to 
haemorrhage. In which case also, it has been remarked that there is 
an increased liability to diseases which are the sequela? of labor, such 
as phlegmasia dolens ; and, in the case of epidemic metria, that disease 
is apt, when it attacks a chlorotic woman, to assume some one of its 
more rapid and fatal forms. The treatment of the chlorosis of preg- 
nancy is to be conducted on the same principles as under other circum- 
stances. It will thus consist mainly in careful attention to the general 
health, special attention being given to the diet, which should in all 
cases be generous, and contain a considerable proportion of animal 
food. Stimulants in some form are also indicated, the red wines of 
Bordeaux, Burgundy, and Hungary, being perhaps superior to all 
others in the treatment of this class of diseases. In this respect, how- 
ever, tastes as well as constitutions vary considerably, but, as a rule, 
the milder stimulants will be found to suit better than those of greater 
alcoholic strength, unless, indeed, sinking, or even collapse, the result, 
it may be, of some form of haemorrhage, should call for more energetic 
measures. The only class of medicines which stand prominently in 
advance of others in the treatment of chlorosis are of course the various 
preparations of iron, which should therefore in every case be tried. If 
the bowels are constipated, the iron should be combined with a laxa- 
tive; but our own impression is, as has already been observed, that it 
is, as a rule, less efficacious in pregnancy than under other circum- 
stances. 

Plethora, in its wider sense, is a comparatively rare affection of preg- 
nancy. Local Plethora or congestion is of course common enough, 
and is the result generally of mechanical pressure, exercised either upon 
the organs affected or upon venous trunks. A certain number of cases 
do, however, actually occur in those whose temperament renders them 
liable to hyperemia. In those instances, the symptoms of pregnancy 
are different from such as are ordinarily observed, but are by no means 
rendered more bearable. In fact, the vertigo, ringing in the ears, 
flushing, and severe headache greatly aggravate the discomfort of the 
woman. If these indications are disregarded, and the symptoms un- 
checked, nature may relieve herself by the spontaneous occurrence of 
haemorrhage; and, if the flow of blood should take the direction of the 
utero-placental, or utero-decidual system, a very natural result will be 
the premature expulsion of the foetus or embryo. The treatment 
proper to such cases will consist, in the milder form, of simple regula- 
tion of the diet and mild laxatives. We must not here, as in the chlo- 
rotic cases, encourage our patient to use animal food with freedom ; but, 
on the contrary, we must enjoin abstinence, complete if need be, from 
such articles of diet, and even from the milder stimulants, — light soups, 
cooling drinks, and a large share of vegetables being substituted for 
more stimulating materials. Our object here is to keep the supply in 



XIII.] PLETHORA. 229 

proper balance with the assimilative powers, so as to reduce the ten- 
dency to hypersemia ; and our efforts in this direction with be greatly 
aided by the use of laxatives, of which the salines are the best for the 
purpose, beginning, perhaps, in the first instance with a more active 
cathartic. When the symptoms are so severe as to lead us to appre- 
hend serious results, such as convulsions, we may fearlessly have re- 
course to bloodletting, which may be practiced from the arm in the 
usual way ■ or, if there be evidence of a special determination of the 
blood in any one direction, such as the brain, the kidneys, or the 
womb, local abstraction of blood by leeches or cupping-glasses may in 
these instances be preferred. In such cases the bleeding must be fol- 
lowed by the general treatment above indicated, which should be 
rigorously maintained, it may be continuously, or at such intervals as 
seem necessary, during the whole course of the pregnancy. 

The pressure which, during the pregnant state, is exercised upon 
venous trunks, gives rise to a number of symptoms which are thus due 
to a cause purely mechanical. Among the more common of these is a 
varicose condition of the veins of the legs and lower part of the trunk, 
which, when trifling, may be disregarded, but, when severe, should be 
treated by bandages, the pressure of which must be carefully regulated. 
Should this condition of the veins have preceded impregnation, the 
symptoms may be so severe as to suggest to the mind the possibility of 
relief by some operation with a view to a radical cure. It need 
scarcely be said, however, that, under the circumstances of pregnancy, 
the chance of a favorable result from any such operation is extremely 
improbable ; and, moreover, the immediate effect of the operation might 
be to disturb the progress of gestation. Haemorrhoids spring from the 
same mechanical cause as the preceding affection, and are besides very 
greatly aggravated by the habitual constipation which is of such fre- 
quent occurrence during pregnancy. However severe the suffering 
may be to which they give rise, there are scarcely any circumstances 
which would warrant us in excising, ligaturing, or otherwise operating 
with a view to the cure of this troublesome affection. Nor is it proper 
even to apply leeches to the part, if it be true, as has been asserted, 
that these may cause abortion ; and, besides, Desormeaux tells us that 
he has never known the application of leeches to, or incision of, these 
tumors in pregnancy attended with any durable amelioration in the 
symptoms. The treatment of haemorrhoids must consist, therefore, in 
measures which are purely palliative. If they are painful, sponging 
with warm water, or fomenting with sponges wrung out of hot water 
and applied successively as hot as can be borne, is often attended with 
the greatest possible relief and comfort. Of local applications, nothing 
perhaps is superior to the well-known Unguentum Gallse cum Opio. 
Where haemorrhage is a prominent symptom, it may be necessary to 
employ more active astringents, but what is more useful is cold injec- 
tions, which may be quite freely used without risk. 1 It is doubtful 

1 Cazoaux recommends the administration every night of a full enema, to be 
given cold, and when this has been evacuated, a second is to be given, about a fourth 
of the bulk of the first : the latter to be retained. 



230 DISEASES OF PREGNANCY. [CHAP. 

whether cold hip-baths are advisable, as the risk in that case of excit- 
ing uterine action is increased. 

We have already observed, as a sign of pregnancy, the distended con- 
dition of the small veins of the vagina, which gives rise to an alteration 
of the color of the part to a different tint. If the pressure be unusually 
great, these veins may assume a varicose appearance, but if this only is 
the result, no interference is necessary, and the inconvenience is but 
trifling. In another and more severe class of cases, rupture of the dis- 
tended vessels takes place, and the result is the formation of a livid 
tumor, usually limited in extent, and situated for the most part in one 
or other of the labia. This tumor constitutes a Thrombus of the 
vagina. Its appearance, which is usually sudden, is attended with con- 
siderable pain, and its immediate cause, in many instances, is to be 
traced to blows, falls, or violent efforts of any kind. It is very variable 
in its course and termination, and may end by resolution like a throm- 
bus in any other situation, in which case it is of very short duration. 
It may terminate also in rupture, which gives exit to the pent-up 
blood, and may thus give relief and lead to a speedy cure; or the 
haemorrhage may be so excessive as to cause great apprehension, and it 
has even terminated in death. In other cases, suppuration and gan- 
grene have been the immediate effects, and from the latter process a 
fatal result has also ensued. The condition of the parts during preg- 
nancy renders this affection more serious than when it is independent 
of the process of gestation, and it is not until delivery has taken place 
that we can look for cure. This is, however, by no means always the 
case, for the relaxation which then occurs facilitates the further effusion 
of blood, and we may therefore have, immediately after delivery, a 
serious increase in the bulk of the tumor. For a similar reason, throm- 
bus is occasionally developed for the first time after labor, and in these 
cases there is more danger of its acquiring a considerable size. 

The treatment of vaginal thrombus is a point of great nicety and 
importance. In those cases in which there seems to be a tendency 
towards resolution, and in which the density of the tumor becomes 
increased while its bulk diminishes, no active interference is called for, 
and our duty is simply to watch the progress of the case, lest circum- 
stances should arise to call for prompt action. In cases, on the other 
hand, where the tumor is of large size, so as to fill a considerable 
portion of the pelvis, and form an obstacle to the functions of surround- 
ing parts ; or when it is fluctuating throughout, showing that it contains 
a vast reservoir of fluid blood, and when there is reason to believe that 
the haemorrhage into the tissues is still going on ; or, again, when there 
is pointing and other evidence that at any moment spontaneous rupture 
may occur — and in all these cases evidence that the vital powers are 
on the wane — we cannot hesitate, but must act by at once incising 
and giving vent to the effused blood. The two groups of cases above 
cited are extremes, but there is another, forming probably the largest 
number of all, which may be supposed to occupy a place intermediate 
between them. In this class, while the symptoms are neither such 
as to make us confident in the approach of resolution nor to cast 
aside as injudicious the idea of further delay, we are constrained to 



XIII.] THROMBUS OF THE VAGINA. 231 

wait, with varying hope and apprehension, as long as the health of 
the woman will admit of it, until the features of the case become so 
marked in one direction or another that our course of procedure is 
definitely fixed. A special class of cases are those in which a thrombus 
during labor threatens to be an actual impediment to its progress, and 
in which for that reason, irrespective of others, it may be necessary to 
operate. 

In all cases in which incision has been determined upon, we must in 
the first place take care to make the aperture a free one, for if a small 
opening only is made, nothing will escape but fluid blood, and all the 
clots, which constitute probably the greater portion of the bulk of the 
tumor, will be left behind. If the clots are adherent, or firmly inclosed 
in the interstices of the tissues, care must be taken in dislodging them, 
lest we should unnecessarily give rise to fresh haemorrhage. As regards 
the point of the tumor at which we are to operate, we must, in the 
first instance, be guided by the fact whether or not there is any indica- 
tion of pointing, and, if so, our choice must fall upon the site so indicated. 
But if there be no pointing, and seeing that the thrombus is very 
generally situated in the labia, and has thus a cutaneous and a mucous 
surface, the question arises through which of these is the incision to be 
made. On this point, most of those who have written on the subject 
are agreed that to make, the opening from the cutaneous side gives the 
patient the best chance. The freer exit for the discharges, the protec- 
tion of the wound from the lochial and other irritating fluids, and the 
improbability of there being in future labors a cicatrix which might 
again give way, are among the reasons which have been urged in favor 
of this mode of procedure. The inflammation which usually supervenes 
upon the operation must be combated by appropriate means, such as 
strict cleanliness, and appropriate lotions and injections. The prog- 
nosis of all such cases is far from favorable. " Of sixty-two cases," 
says M. Deveux, " which have come to my knowledge, the women died 
in twenty -two, either during pregnancy, or labor, or afterwards. And, 
with the exception of one case, all the children of these twenty-two 
women died." 



232 DISEASES OF PREGNANCY. [CHAP. 



CHAPTEK XIV. 

DISEASES OF PREGNANCY (Continued). 

IV. DISORDERS OF SECRETION AND EXCRETION — PTYALISM — INTERFERENCE WITH 
FUNCTION OF KIDNEYS AND BLADDER — RETENTION : MECHANICAL OR FROM 
PARALYSIS — ALBUMINURIA: STATE OF THE BLOOD IN : PECULIARITIES OF THE 
PUERPERAL FORM : CONNECTION OF WITH PUERPERAL CONVULSIONS ! SYMP- 
TOMS, PROGNOSIS, AND TREATMENT — THE PHOSPHATIC DIATHESIS IN PREG- 
NANCY — LEUCORRHCEA AND GRANULAR VAGINITIS — ASCITES — DROPSY OF THE 
AMNION — HYDRORRHEA. V. DISORDERS AFFECTING LOCOMOTION — PELVIC 
articulations: relaxation of: INFLAMMATION OF. VI. DISORDERS AF- 
FECTING THE NERVOUS SYSTEM — AFFECTIONS OF THE SPECIAL SENSES — EFFECT 
ON THE MORAL AND INTELLECTUAL FACULTIES — ABDOMINAL AND UTERINE 
PAIN. VII. DISPLACEMENTS OF THE GRAVID UTERUS — PROLAPSUS — ANTEVER- 
SION AND ANTEFLEXION : SYMPTOMS AND TREATMENT OF — RETROVERSION | 
HOW CAUSED ORIGINALLY: CHRONIC AND ACUTE FORMS: SYMPTOMS AND 
TREATMENT OF EACH: OPERATION FOR THE REDUCTION OF — OBLIQUE DIS- 
PLACEMENTS. 

IV. Disorders of Secretion and Excretion. 

Ptyalism, which has already been mentioned as a concomitant of 
pregnancy, is occasionally excessive, and may thus give rise to such 
annoyance as to cause the woman to apply for relief. It has generally 
been observed as an affection of the first weeks of pregnancy only, and 
rarely lasts more than two months : if it be excessive, or of longer 
duration than usual, it may be relieved by the use of gum arabic, 
tamarind-water, ice, or some gentle astringent. 

The Function of the Kidneys is not, as a rule, in any way disturbed 
by gestation. 1 It is, however, otherwise as regards the Bladder, which, 
from its situation, is peculiarly liable to be affected in its function by 
the pressure to which it is subjected. Annoyance from this source is 
seldom experienced in the early months of pregnancy, but, in the last 
weeks, when the uterus has fallen downwards, as is usually the case 
prior to delivery, the pressure then brought to bear upon the neck of 
the bladder, which is compressed between the head of the child and 
the symphysis, may give rise to intolerable annoyance, for the relief of 
which, prompt action is frequently required. In many cases, the 
woman is able to relieve herself perfectly by placing herself on her 
knees and elbows, when, the weight of the child being transferred to 
the fundus of the womb, the mechanical obstacle is at once removed, 

1 The formation of Kiestein has already been referred to. See " Signs of Preg- 
nancy." 






XIV.] ALBUMINURIA. 233 

and she is able to micturate without difficulty. The cases in which the 
greatest amount of difficulty exists are those which are accompanied by 
anteflexion of the womb, when the pressure upon the bladder is for 
obvious anatomical reasons more severe. Complete retention of urine 
is occasionally the result, and, in such a case, the bladder may become 
enormously distended, and, in an unnaturally elongated form, may 
reach as high as the umbilicus ; and, indeed, cases have been recorded 
in which death has taken place from rupture of the bladder, and escape 
of the urine into the peritoneal cavity. Fortunately, however, it is 
only on rare occasions that the retention is complete, but it is by no 
means unusual for the practitioner to be summoned to relieve the almost 
constant irritation from which the woman suffers, in consequence of the 
difficulty which she experiences in her efforts to empty the bladder. 
If this difficulty is not relieved by change of posture during the act, 
an abdominal bandage, carefully adjusted, and worn so as to give sup- 
port to the uterus, will often be productive of the most satisfactory 
results. But, failing such means, it will be necessary, in some instances, 
to use the catheter, and in this manner to relieve the bladder. With 
the ordinary female catheter, considerable difficulty may often be ex- 
perienced, as it is too straight and too short to be adapted to the 
altered anatomical relations of the urethra and bladder; and, indeed, its 
use is not free from risk. It is, therefore, much better to use an elastic 
catheter, by means of which the operator will, even in cases of complete 
retention, rarely fail to effect his purpose. In cases where the com- 
pression is comparatively trifling, it may act in another way, by inducing 
paralysis of the sphincter vesica?, and a constant escape of the urine 
drop by drop. In one case, this was observed by Scanzoni as early as 
the third, and disappeared entirely so soon as the uterus had risen out 
of the pelvis in the fourth month. Catheterism may be employed as 
often as is necessary; and the catheter may be left in for several hours, 
while the woman lies quietly on her back, should the symptoms not 
yield to the simple emptying of the bladder. Sometimes, in the last 
months, she experiences a smarting or more severe pain, in micturating, 
which has been found to depend, in many instances, upon a catarrh of 
the bladder, or at least of its neck ; under which circumstances, whitish 
flakes and purulent matter in the urine will disclose the nature of 
the case, for the treatment of which, the only safe means which can 
be adopted are baths, bland drinks, and emollient applications. This 
affection may be associated with spasm of the neck of the bladder, 
which may also exist independently of any local disease, the irritation 
which causes it being sometimes due to pressure, and at other times to 
a reflex irritation starting from the uterus. 

The existence of Albuminuria as a disease of pregnancy, was first 
discovered by M. Rayer, and in this country was brought under the 
notice of the profession by Dr. Lever. Previous to this, there can be 
no doubt that many cases were set down simply as instances of oedema, 
due to pressure (the (Edema Gravidarum of the old writers), which 
were, nevertheless, caused by the presence of albumen in the urine, or 
by the changes in the kidneys upon which that symptom usually 
depends. Under ordinary circumstances, the presence of albumen in 



234 DISEASES OF PREGNANCY. [CHAP. 

the urine is looked upon as symptomatic of very serious organic disease, 
and experience abundantly shows that we have only too good reason to 
look forward in such cases with somewhat gloomy anticipations as to 
the future. There are, however, exceptional instances, such, for exam- 
ple, as arise in the course of scarlatina, in which our prognosis is vastly 
more favorable. A knowledge of these facts has given rise to numerous 
speculations as to the nature and exact import of the symptom, when it 
is observed in the course of pregnancy. The question, in fact, is — are 
we to consider the albuminuria of pregnancy as indicative of serious 
disease of the kidneys; or are we, on the other hand, to look upon it 
as an exceptional symptom of pregnancy, and one to the disappearance 
of which after delivery we may confidently look forward ? In consider- 
ing, in the light of modern investigation, what answer should be given 
to this query, we note, in the first place, the fact that the albumen in 
the blood is somewhat diminished during pregnancy. Along with this 
we have the researches of Blot and Litzinann, who, by a series of inde- 
pendent observations, have shown that albumen exists in the urine in 
more than twenty per cent, of pregnant women ; and in the case of 
primiparse, the percentage is considerably higher even than this. If 
Ave were to admit, therefore, that albumen in the urine was here a 
pathognomonic sign of equal significance with that which occurs inde- 
pendently of gestation, we must conclude that the mortality of preg- 
nancy and childbed would be thereby in a very great degree augmented. 
But, as experience shows us the contrary, we are thus, on the very 
threshold of the inquiry, forced to admit that the albuminuria of preg- 
nancy is comparatively an innocuous disease. 

That childbed mortality is, directly or indirectly, increased in some 
measure by the presence of albumen in the urine, and the associated 
phenomena, is a fact which no one in these days will gainsay. Among 
the phenomena here alluded to are puerperal convulsions, a subject to 
which we shall, at a later period, have occasion specially to refer, as the 
affection in question is one upon which the most serious results not un- 
frequently ensue. This is, in fact, one of the most interesting and 
practically important points in connection with the subject; to the 
demonstration of which Simpson contributed in no small measure, by 
establishing the intimate association which exists between convulsions 
and albuminuria. But, the unhappy results which frequently attend 
this complication fortunately do not indicate the ordinary course of an 
uncomplicated case of albuminuria in pregnancy. The frequency with 
which this alteration of the urine is to be observed, as has been shown 
by the observations of Blot and Litzmann already referred to, is suffi- 
cient to prove that a large proportion of cases are unattended by any 
marked symptoms, and, therefore, we may assume, run their course 
without the nature of the case being so much as suspected. And, more- 
over, this idea receives the strongest possible confirmation from the 
fact which experience has fully disclosed, that, in the majority of cases 
in which albumen is actually detected in the urine by chemical exami- 
nation during gestation, the general health is little if at all affected, 
and the normal constitution of the urine is restored within a short 
period after delivery. 



XIV.] TREATMENT OF ALBUMINURIA. 235 

The symptoms of this affection are, then, in the mildest cases, either 
such as to attract no attention, or are confounded with those which 
naturally arise from, or are associated with, the pregnant state. When, 
however, dropsical effusion takes place, — which is not, like that which 
has already been alluded to as the result of mere mechanical pressure, 
confined to the lower limbs, but affects more or less extensively the 
whole body, — our suspicion should be at once aroused, and a careful 
examination instituted, when the presence of the abnormal element in 
the urine will usually be detected. In extreme cases, the legs are enor- 
mously swollen, and the vulva and vagina tumefied; and the charac- 
teristic puffiness of the face, with swelling of the upper limbs and of 
the abdominal walls, indicate still more clearly the nature of the case. 
The urine is scanty, of high specific gravity, and may become solid 
on boiling. In the worst cases, and especially in those in which con- 
vulsions occur, there is considerable headache, dimness of vision, and 
amaurosis, — which latter sometimes conies on quite suddenly, imme- 
diately before a fit. The blood poisoning, which gives rise to these 
epileptiform seizures, consists, as the observations of Christison and 
others have conclusively shown, in the presence in the blood of urea, 
which is not eliminated in consequence of the perverted condition of 
the renal function. It has been demonstrated experimentally, that 
placing a ligature on the renal veins, and thereby disturbing the 
balance of the circulation in the kidneys, causes the appearance of 
albumen in the urine. From this the inference has been drawn, that 
the albuminuria of pregnancy was due to the pressure exercised by 
the gravid uterus. That this is the case in many instances we cannot 
doubt, but at the same time we are inclined to believe that the expla- 
nation has been too readily accepted as the solution of every case. 
The fact of its greater frequency in primiparae and in twin pregnancy, 
where the pressure is obviously greater, no doubt lends confirmation 
to the view alluded to ; but, on the other hand, instances occasionally 
occur in which, at an early period of pregnancy, albumen may be de- 
tected before any such pressure as would account for it on the above 
hypothesis could by any possibility occur. "In such cases," says Dr. 
Tyler Smith, "the disease appears to me to depend upon reflex irrita- 
tion of the kidneys by the gravid uterus, similar to the irritation of 
the salivary glands, the mammae, thyroid, etc., and not upon mere 
pressure alone." If the symptoms continue unchecked, the general 
health of the patient becomes seriously compromised. The anaemia 
and waxy pallor which is so characteristic of the more advanced stages 
of Bright's disease now become manifest. This is supposed by modern 
pathologists to be due, mainly, to the poisoning of the blood by the 
urea, which takes the place in that fluid of the lost albumen ; while, 
by subsequent decomposition, the urea is converted into ammonia, 
which has been detected in the blood and in various secretions. 

The existence of puerperal albuminuria, is, as a rule, only recognized 
during the last months of pregnancy. It by no means follows, how- 
ever, that this marks the period at which it is first present in the urine. 
On the contrary, we may be certain that its recognition is often deferred 
to that period, simply because the symptoms have not been such as to 



236 DISEASES OF PREGNANCY. [CHAP. 

attract particular attention. There is too good reason to believe, indeed, 
that, even in cases where the symptoms ought to have excited suspicion, 
the idea has never been entertained until the occurrence, during labor, 
of violent convulsions, for the first time directs attention to the fact. 
The greatest variety exists in the progress and duration of the disease. 
In some of the cases which have been most carefully noted, the presence 
of the albumen has not been constant, but has either oscillated in regard 
to quantity, or has ceased completely for days, to return again, — thus 
repeatedly intermitting during a considerable period. In others, the 
affection appears to gain ground as the pregnancy advances, and ulti- 
mately to culminate in that form of granular degeneration of the kidney 
which constitutes the disease of Bright. There are, of course, cases in 
which women who are already the subjects of Bright's disease become 
pregnant, and in whom all the symptoms suffer aggravation. But what 
we refer to at present exclusively are those cases in which, at some 
period in the course of a pregnancy, albuminuria makes its appearance 
for the first time. The instances in which no serious kidney lesion 
exists, constitute, happily, the great majority. In such, the albumen 
usually disappears shortly after delivery ; but, in others (as we not 
unfrequently see after scarlatina), the albumen persists for many months, 
although the general symptoms are not necessarily severe. Much in- 
formation may be derived, in doubtful cases, from a microscopic exam- 
ination of the urine ; and in this way, too, our prognosis will, in a 
great measure, be formed, as the presence of tube-casts, and their mi- 
croscopic characters, will often reveal the nature and stage of the renal 
degeneration, should it exist. Headache, sickness, and the various 
forms of digestive disorder which are so frequently associated with 
pregnancy, are, under the influence of albuminuria, often greatly 
aggravated ; and there can be no doubt that the morbid alteration in 
the blood gives rise, as has been observed by M. Blot and by Tyler 
Smith, to dangerous haemorrhage during or after labor. 

In reference to the question of treatment, it is obvious that it must 
be of no small importance to ascertain, as early as possible after its 
development, the presence of the albumen. More especially is it of 
importance to be possessed of this information, in order that we may 
adopt such measures as may remove, or at least mitigate, the symptoms, 
before the period of labor arrives, at which experience teaches us to 
dread the occurrence of convulsions, and the alarming results which 
spring from uremic poisoning. In every case in which the symptoms 
point in that direction, including even the minor forms of oedema, it is 
well, as a matter of routine in practice, to test the urine for albumen. 
Its presence may, doubtless, be discovered in many cases in which no 
other symptoms exist, and the health of the woman is excellent. If so, 
the treatment will consist in careful regulation of the diet and of the 
functions, and in occasional observations of the urine, with the view of 
obtaining the earliest possible information of any morbid change. If 
the case is one wholly due to pressure, no serious symptoms whatever 
may be manifested, and the case may continue until the end of preg- 
nancy, with the result of a happy labor and perfect recovery. If the 
general system seem to participate in the morbid process, and there is 



XIV.] TREATMENT OF ALBUMINURIA. 237 

lumbar pain and general febrile excitement, great relief will frequently 
follow the application of a few leeches to the loins, to be followed by 
diligent fomentation. Antiphlogistic treatment of any kind, more 
especially in such cases as are not observed until the disease has made 
some progress, must be resorted to with the greatest caution. For it must 
be remembered that the disease is one of debility, and implies impov- 
erishment of the blood — a condition which calls more for a tonic treat- 
ment and a generous diet. Baths of various kinds are often useful, 
being at once grateful to the feelings of the patient and likely to pro- 
mote the function of the skin. The use of diuretics has also been rec- 
ommended ; but, if used, these agents should be employed cautiously, 
and in the mildest form. In a case which came under our observation 
lately, a lady aged thirty-four, pregnant for the first time, had oedema 
of the ankles about the beginning of the sixth month, when a trace of 
albumen was discovered — the urine being very scanty, high-colored, 
and loaded with lithates. The treatment adopted was the bitartrate of 
potash, with Rochelle salts and benzoic acid, which kept the symptoms 
somewhat in abeyance, and manifestly improved the function of the 
kidney. The general health did not deteriorate, but the general dropsy 
increased, the quantity of albumen in the urine fluctuating considerably. 
All went on well, but, in the last stage of a tedious labor, the patient 
was seized with a most violent epileptiform attack. She was at once 
delivered with the forceps, made a good recovery, and in six weeks all 
trace of albumen had disappeared. In the above case, the benzoic acid 
was given, as recommended by Frerichs, with the view of neutralizing 
the ammonia which forms in the blood from the decomposition of the 
retained urea. 

[We have frequently derived great advantage from the use of digitalis 
and acetate of potash in the albuminuria of pregnancy. The digitalis 
should always be given in infusion. Alcoholic preparations of this 
drug do not by any means possess the diuretic properties which belong 
to the infusion. If there is anaemia, the acetate of potash should be 
given with Basham's mixture, with which it combines well. The latter 
may be prepared according to the following formula: 

R. Tinct. Ferri Cblor., fgiij. 
Liq. Ammoniae Acet., f^iij. 
Acid. Acetic, t^xv. 
01. G;iultherige, gtt. v. 
Syr. Aurantii cort., f^j. — M. 

Sig. Dose one to two drachms three times daily. — P.] 

The significance of albuminuria during pregnancy has been viewed 
by some as of such serious import as to warrant the induction of prem- 
ature labor ; but to such an opinion, in so far as ordinary cases are 
concerned, we are unable to subscribe. So serious, however, is the 
probable issue of a case in which the quantity of albumen, the degree 
of oedema, and the general condition of the patient, tend to indicate 
the highest grade of severity in the symptoms, that we may be quite 
justified in entertaining gravely the propriety of such a course. But, 
in such circumstances — and the remark applies equally to all cases in 
which the question of premature delivery may arise — it is proper not 



238 DISEASES OF PREGNANCY. [dlAP. 

finally to resolve upon such a step without, if possible, obtaining the 
sanction and approval of some colleague in whose opinion we may have 
confidence. 

Dr. Tyler Smith has pointed out, as an occasional accompaniment of 
pregnancy, the habitual occurrence of a large quantity of triple phos- 
phate in the urine, which, under the circumstances, is of high specific 
gravity, and has an alkaline reaction. The same observer has noticed, 
further, that in some cases in which this phosphatic diathesis has been 
found to exist, fatty degeneration of the placenta had occurred in suc- 
cessive pregnancies. The treatment of such cases consists in the use of 
the mineral acids, opiates, rest, and a nutritious regimen. 

A hypersecretion of the mucous membrane of the vagina constitutes 
a troublesome form of leueorrhcea, which is of frequent occurrence 
during pregnancy. A certain degree of this increase in the action of 
the glandular structures is to be looked upon as an ordinary accompa- 
niment of pregnancy, due to the increased vascularity which is insepa- 
rable from gestation, and which manifests itself, as we have already 
seen, in a change in the color of the membrane. This, of course, re- 
quires no treatment beyond ordinary attention to cleanliness. But the 
quantity of the discharge is occasionally excessive, and varies greatly 
in its appearance, being in one case clear, in another milky, and in a 
third yellow and creamy like ordinary pus. Such a condition is found 
occasionally to be associated with a growth of papillary projections on 
the surface of the membrane, which are sometimes as large as small 
peas, but more generally very minute and spreading over the whole 
vagina, giving to it a granular appearance. This is what has been 
called vaginitis granulosa, an affection accompanied with irritation and 
uneasiness, amounting in some instances to pretty severe pain, or, what 
is even worse, intolerable itching of the parts. The latter symptom 
may give occasion, even during sleep, to rubbing and scratching of the 
vulva, which may cause ultimately severe excoriation, and much suf- 
fering. When circumstances render it probable that a specific cause 
exists, we must of course be on our guard against mistaking gonor- 
rhoea! or syphilitic discharges for that which we are now considering; 
and, in cases where the diagnosis may be difficult, the presence of con- 
dylomata and other unequivocal specific appearances will serve to re- 
move all doubt. Generally, when the affection is due to pregnancy, 
even the most profuse discharges rapidly disappear after delivery, and 
seldom attract any notice after the lochia have ceased to flow. Cases, 
however, occasionally occur in which such a discharge, originally ap- 
pearing during pregnancy, lasts during the convalescence after labor, 
and ends in an obstinate and troublesome vaginal leueorrhcea. The 
treatment of this affection must necessarily be confined within certain 
limits, so that sometimes palliation is the most we can hope for. Cau- 
terants, or strong injections, cannot be employed, lest they should in- 
duce premature labor, and even the simplest injections must, if used, 
be employed with the greatest possible caution, as it is well known 
that repeated injections, even of tepid water, will often suffice to induce 
uterine contractions. The resources at our command are, on this ac- 
count, extremely limited, and in most cases must consist in cleanliness, 



XIV.] LEUCORRHCEA. 239 

warm baths, and emollient applications. Medicated pessaries of various 
kinds, such as those which are made with tannin, or with alum and 
catechu, may also be used with safety and with every prospect of suc- 
cess. If there is much irritation or itching, the ingredients may be 
varied at w r ill to meet these indications. 

General dropsy, as symptomatic of, or coincident with puerperal 
albuminuria, has already been fully noticed. There are other forms, 
however, of dropsical disease which require attention, among which 
are ascites, dropsy of the amnion, and the affection known as hydror- 
rhcea, each of which calls for special remark. Ascites is a form of 
dropsy, familiar to the physician, which takes the form of effusion 
within the peritoneal cavity, and which is of frequent occurrence 
during pregnancy. Sometimes it is developed at an early stage of 
gestation, in which case we should look upon the symptoms with con- 
siderable apprehension, as experience has shown that the result is. not 
unfrequently, fatal to child or mother, or to both. It is rare, however, 
that it develops itself before the fifth month, and if the patient reaches 
the termination of the sixth month without ascites, it is unusual for 
the symptom to manifest itself for the first time after that period. A 
certain amount of effusion may take place within the peritoneal cavity 
without attracting any special attention, but as pregnancy advances, 
the amount of distension is out of all proportion to the stage which 
has been reached. Examination by the usual process of palpation 
discloses the fact, in the same manner as under ordinary circumstances, 
but the site of the chief effusion is varied somewhat in consequence of 
the presence of the distended uterus. On that account, fluctuation will 
be perceived most distinctly in the hypochondriac regions, and especi- 
ally on the left side. The distension, as the case goes on, continues to 
increase, to such an extent as to press injuriously upon the diaphragm 
and disturb the functions of the thoracic organs, while the amount of 
mechanical pressure is further shown by the projection of the umbili- 
cus, which often takes the form of a protrusion several inches in length, 
and as translucent as the scrotum in hydrocele. The abdominal walls 
become cedematous and pit on pressure, and if the case is still un- 
checked, the whole body becomes enormously swollen, while the blue 
lips, labored breathing, and rapid feeble pulse show how much the 
general functions are disturbed. In the course of such a case, the 
diagnosis of pregnancy is seriously interfered with, and it may be im- 
possible to make out the presence either of a solid body or a distended 
uterus; and, besides, there is good reason to believe that, the uterus 
being separated to a greater or less extent from the abdominal walls, 
the sensation of quickening is deferred to an advanced period of ges- 
tation, or in some cases is never felt at all, although the child is alive 
and vigorous. The worst cases of all are those in which ascites is 
complicated with dropsy of the amnion, when the prognosis is very 
unfavorable. 

Caution must be exercised in the treatment of puerperal ascites, in 
so far as the use of drugs is concerned. It would appear, indeed, that 
not only is the free use of purgatives and diuretics prejudicial to the 
pregnancy, and apt to bring on labor, but also that those agents have 



240 DISEASES OF PREGNANCY. [CHAP. 

very little effect, in such cases, in checking the advance of the malady. 
We ought, however, always to try them before resorting to other 
measures; but, should they fail, and the distension be such as to 
threaten the life of the woman, we have no choice left save between 
paracentesis and the induction of premature labor. In deciding be- 
tween these two modes of procedure, we must be guided by the pecu- 
liarities of individual cases. The operation of paracentesis will be pre- 
ferred in all such as may show a reasonable prospect of thus relieving 
the woman and allowing the pregnancy to run its course, thereby 
saving both mother and child. It must be remembered, however, that 
the operation is very frequently succeeded by uterine contractions, so 
that the very measure which is adopted with a special view to the 
safety of the child, may possibly be the cause of its expulsion. In 
regard to the operation itself, it is clear that we cannot, without incur- 
ring the risk of wounding the gravid womb, operate in the ordinary 
situation ; so that another site must be selected. Scarpa operated in 
the left hypochonder, and Ollivier punctured on several occasions the 
protruding umbilicus with an ordinary lancet, and either of these 
modes of procedure might be adopted in cases where the operation had 
been, after due consideration, resolved upon. We confess, for our 
part, that, seeing the frequency with which premature labor has fol- 
lowed spontaneously upon the operation of paracentesis, and the risk 
of peritonitis which the woman must run as a consequence of it, we 
look with more favor on the induction of premature labor as the proper 
measure to resort to in extreme cases. The nearer such a case ap- 
proaches to the full term of gestation, the less need we hesitate in 
adopting this course; but even when it involves the certain loss of the 
child, we believe that the most judicious course would be to adopt this, 
in preference to paracentesis. 

Dropsy of the Amnion. — There is, as has already been observed, a 
very great variety, consistently with quite normal gestation, in the quan- 
tity of the liquor amnii. It is, therefore, a matter of no little difficulty 
to determine the point at which the quantity becomes abnormal, but 
we shall probably not be w r ide of the truth if we put down the limit at 
from two to three pints ; so that, if the quantity should exceed this, the 
case may be held to come under the category of dropsy of the amnion. 
In extreme cases, from thirty to forty pints of fluid have escaped from 
the uterus. It was at one time generally believed that this form of 
dropsy was associated with some special morbid condition. It has 
been supposed, for example, to be due to inflammation of the amnion, 
constitutional syphilis, or to some diseased condition of the foetus; but, 
although all these theories are possible, none of them have up to this 
period been demonstrated. It seldom has been observed before the 
fifth month, and is much more frequent in twin pregnancies. 

If any difficulty should be found in distinguishing between ascites 
and dropsy of the amnion, attention to the following points, which are 
laid down by Cazeaux as diagnostic, will generally enable us to make 
the distinction, if the cases are uncomplicated ; but it must not be for- 
gotten that the two affections may coexist. In ascites, the urine is 
scanty and thick, and the lower limbs and genitals are cedematous. 



XIV.] HYDRORRHEA. 241 

There is also fever and constant thirst. It is difficult, if not impossi- 
ble, to recognize the outline of the uterus, and in the course of our ex- 
amination by palpation, distinct fluctuation is to be detected. In 
dropsy of the amnion again, there is normal urine and little thirst. 
The lower limbs are often perfectly free from oedema, or if it be present, 
it is so to a comparatively small extent. The rounded form of the dis- 
tended uterus can generally be made out, but the fluctuation is very 
deepseated and obscure. There is rarely any umbilical projection, 
and if so, it is not transparent. The distension from dropsy of the 
amnion is sometimes enormous, and may threaten death by apnoea, by 
interfering with the function of the lungs. The natural relief which 
has, in such cases, followed upon spontaneous rupture of the mem- 
branes and the escape of the fluid, points very clearly to the only 
method of treatment upon which we can rely; for, whatever may be 
the opinions entertained with reference to ascites, there can be no doubt 
that, in the affection we are now considering, the only operative pro- 
cedure applicable to cases where life is in danger is the induction of 
premature labor by rupture of the membranes. If the symptoms are 
not urgent, and the distension not excessive, careful attention to all the 
functions is the only mode of procedure which can be adopted, seeing 
that diuretics and purgatives are of no avail, and, besides, that the 
pregnancy may possibly come to a satisfactory termination. The result 
of this affection is very serious as regards the life of the child, but sel- 
dom implicates that of the mother, nor, indeed, as a general rule, does 
it seriously aifect her health. The natural result is spontaneous prem- 
ature expulsion. 

Hydrorrhea. — In this singular affection, which has also been called 
" false waters," a discharge of fluid takes place from the uterus, the 
amnionic sac remaining entire, and the phenomenon being neither 
preceded, nor necessarily followed, by uterine contractions. This occurs 
pretty frequently towards the end of pregnancy, and even although the 
quantity of fluid discharged may have been considerable, and lead to 
the idea that premature rupture of the membranes had occurred, labor, 
when it eventually occurs, is found to be accompanied in the first stage, 
as usual, by the formation of the " bag of waters." The circumstances 
under which the discharge occurs vary considerably. In some cases 
it has an obvious connection with some powerful effort or accidental 
violence, while in others it comes on while the patient is at perfect rest, 
or even during sleep. In one case the discharge may occur as a gush, 
in another it may escape guttatim; or, it may come on in either of 
these ways, and then, ceasing completely, may again and again return. 
The discharge is in the first instance at least, attended by no pain, but 
in those cases in which the quantity is large, and the escape sudden, 
uterine contractions are apt to supervene, and premature delivery thus 
to ensue. 

The cause and source of a serous and usually colorless discharge 
which comes from the uterus during pregnancy, and is not the liquor 
amnii, are points of considerable interest, and to account for the phe- 
nomenon many theories have arisen. The only one, however, which 
it is necessary to mention here, as it is that which is almost universally 

16 



242 DISEASES OF PREGNANCY. [CHAP. 

accepted, is that the affection arises from a secretion which has its 
source in the inner surface of the uterus, and which, in proportion to 
its quantity j separates the coverings of the ovum from their uterine 
attachments. A pouch is thus formed between the decidua and the 
womb, which gradually increases as more fluid becomes effused, until, 
making its way downwards towards the cervix, it finds a mode of exit, 
the fluid then escaping into the vagina and making its appearance 
externally. The treatment consists in enjoining strict rest in the 
horizontal posture in order to reduce this risk to a minimum ; and, if 
the gush has been sudden and the quantity large, it will also be proper, 
with the same object, to give an opiate in some form, to allay possible 
uterine excitement. The only practical mistake which might be made 
in such a case would arise from an error in diagnosis, for if we believed 
the discharge to indicate rupture of the membranes, we might, naturally 
enough, rather encourage the coming on of labor, believing that to be 
inevitable. 

V. Disorders affecting Locomotion. — Attention has already been 
directed to the fact, now fully recognized, although long disputed, that 
a relaxation of the various pelvic articulations is an essential and 
physiological accompaniment of the pregnant state. This consists in a 
thickening of the cartilaginous, and a softening and relaxation of the 
ligamentous structures surrounding the articulations in question. Along 
with this, there is a greater afflux of blood to the parts, and the more 
perfect structure of the joints at these times, — as shown, for example, 
in the increased secretion of synovial fluid, — indicates that nature 
makes, as it were, an attempt to establish here what exists in so many 
of the lower animals. The amount of motion which is thus permitted 
is, with the exception of the sacro-coccygeal joint, very trifling in normal 
cases, for were it otherwise the power of locomotion would be seriously 
interfered with. A certain number of rare instances have, however, 
been recorded, which suffice to show that the articulations may be 
relaxed in an unusual degree, and thus a morbid condition ensue. 
Cases have, indeed, been examined by Morgagni, Hunter, and others, 
in which the separation between the pubic bones at the symphysis ex- 
ceeded an inch, and in such cases great increase of the synovial secretion 
has been observed. The woman complains first of pain and uneasiness, 
which is aggravated on walking, or even by a trifling movement of 
the trunk. From being intolerable, locomotion becomes impossible; 
and, on careful examination of the joints, movement, attended with 
synovial crepitations, may sometimes be induced. Absolute rest should, 
as a matter of course, in all such cases, be strictly enjoined, for every 
movement either of the trunk or lower limbs will increase the morbid 
mobility, and by accustoming the joints to move, will render a cure, 
which cannot be looked for till after labor, vastly more tedious. After 
labor — the severity of which this affection will rather tend to mitigate 
— a similar course of treatment must be persevered in, to encourage the 
parts to resume their former condition. This will also be promoted by 
firm bandaging round the pelvis, so as to bring the ossa innominata 
more firmly together, and by the use, it may be, of some more rigid 
mechanical support, such as the steel girdle devised by Martin of Berlin 









xiv.] pain. 243 

We have known, under such circumstances, locomotion rendered im- 
possible for many months after delivery. Inflammation of the pelvic 
articulations is another occurrence which may call for attention, but 
cases of this affection are extremely rare. 

Locomotion, which is, with few exceptions, somewhat impeded in 
the last months of pregnancy, may be rendered extremely painful, or 
at least very uncomfortable, by many of the affections which Ave have 
been considering. Cases, for example, of relaxation of the abdominal 
walls in pluriparse and the anteversion of the womb, which often' ac- 
companies it, are often attended with this inconvenience, which, under 
such circumstances, may be greatly relieved by the use of an abdominal 
bandage, so adjusted as to support the displaced womb. 

VI. Disorders affecting the Nervous System. — The extent to which 
these may be multiplied by classification is almost illimitable. We 
shall here, however, confine our attention to a few only, leaving the 
more important of them to be discussed in a future chapter, and passing 
over such as may be treated on general principles. The functions of 
each of the organs of special sense may be disturbed during pregnancy, 
and we may therefore meet with cases of deafness, aversion to certain 
odors or perfumes which may previously have been deemed agreeable, 
dimness of vision, and even amaurosis, and, as regards the sense of 
taste, peculiarities in this respect are among the most familiar accom- 
paniments of the pregnant state. Vertigo, flushings, syncope, and even 
itching of the skin, in the absence of any cutaneous irritation, must 
also be referred to the same class. Nor do the moral and intellectual 
faculties escape, in all cases, without suffering material disturbance. 
The subject of mental alienation in the puerperal state will hereafter 
be more fully discussed, but there are minor degrees of aberration, 
both moral and intellectual, which do not amount to, or even approach 
insanity, but which are by no means of rare occurrence during gesta- 
tion. Affection may, in this way, be replaced by unaccountable antip- 
athy, a trusting disposition by jealousy, or a temper which can scarcely 
be ruffled by wanton irritability. Amusing cases are even narrated, 
in which an inverse process was the result, and in which whole house- 
holds learned to hail with pleasure the pregnancy of the lady of the 
house, which was divulged to them by unwonted gentleness of manner 
and genial cheerfulness. u It is not uncommon," as Burns says, " to 
find women very desponding during pregnancy, and much alarmed 
concerning the issue of their confinement." This affection, closely 
resembling a similar state occasionally attendant upon disordered men- 
struation, amounts, when extreme, to melancholia, and seems, in both 
cases, to have its origin in an irritation which, starting from the uterus, 
operates reflexly through the nerves. Cheerful society, and careful 
attention to the diet and bowels, constitute, along with other similar 
measures, the only treatment proper to such a case. 

Pain, unconnected either with uterine contraction, or with inflam- 
mation, and referable to any one point in the abdomen, is an occur- 
rence which occasionally, from its severity, calls for interference. In 
a certain number of such cases, there, no doubt, is, as Scanzoni points 
out, an abnormal tenderness of the womb, which many have attributed 



244 DISEASES OP PREGNANCY. [CHAP. 

to rheumatism of that organ, during which either the whole womb, or 
a limited portion of it, may be the seat of very acute pain. When this 
is the seat of the pain, it is usually referred to the hypogastric region ; 
but there are many other instances in which pain of an equally acute 
character is experienced in other regions. Pain in the groins has thus 
been supposed to be caused by dragging on the round ligaments, which 
will be best relieved by an abdominal bandage and the horizontal 
posture. Pain in the lumbar region has, in like manner, although on 
what ground it is not clearly shown, been attributed to stretching of 
the broad ligaments. Pain and cramps in the thighs are most distress- 
ing accompaniments of pregnancy, and are due, in part to pressure on 
the sacral nerves, and in part to a reflex action, starting, most likely, 
from the uterus, but probably, in some instances, from the bowels. 
The abdominal walls also seem, in some cases, to be the seat of acute 
and almost constant pain. This occurs during the last months of 
pregnancy only, and is generally confined to a limited space on the 
abdominal surface — so that it is often difficult to convince the patient 
that it does not mark the seat of some severe local inflammation. All 
such painful affections as we have alluded to must be treated, during 
pregnancy, by the agency of measures which are merely palliative, and, 
in point of fact, palliation is the most that experience of such cases 
teaches us to anticipate. Warm baths in all cases, laxatives in the case 
of cramps, rest and local applications for the relief of the pain, are the 
only agents which, in most instances, can be employed ; for opiates and 
other anodynes are very generally contraindieated, in so far as their 
internal administration is concerned. Among external applications, 
may here be mentioned the soap and opium liniment, chloroform with 
tincture of aconite, and belladonna plasters. In the worst cases, morphia 
may be resorted to, in the form of suppository or subcutaneous injection. 
The increased sensibility of the uterus is, in some of these cases, asso- 
ciated with particularly active foetal movements ; and, very often, pain, 
which has been relieved or deadened, is again awakened by a sudden 
movement, a sneeze, or a cough. 

VII. Displacements of the Gravid Uterus. — Certain displacements or 
dislocations of the womb, which are of frequent occurrence in the un- 
impregnated state, exist also, although more rarely, during pregnancy. 
The reason of the comparative infrequency is to be found in the fact 
that, while in all probability impregnation takes place in some instances 
of uterine displacement, the general effect of the subsequent develop- 
ment of the uterus in the course of pregnancy is to reduce the disloca- 
tion, and thus to avert the disastrous consequences of its persistence. 
As a rule, however, marked flexion or version of the unimpregnated 
organ is a barrier to pregnancy. 

Ln the affection known as Prolapsus or Procidentia, conception may 
occur, and that even in cases where the uterus projects externally. But 
while prolapsus frequently precedes impregnation, the details of some 
cases would seem to show that sometimes the prolapse succeeds the 
conception, the uterus descending instead of ascending as the develop- 
ment progresses, while the further growth of the organ takes place 
without its ever rising into the abdominal cavity. Examples of this 



XIV.] ANTEVERSJON AND ANTEFLEXION. 245 

have been recorded by Portal, and by others whose statements we can- 
not permit ourselves to call in question. In some of these instances 
development has gone on entirely within the true pelvis. Up to a 
certain point, the uterus may no doubt occupy this situation without 
causing any symptoms of discomfort, and this in fact is what takes 
place, as we have seen, in the first three months of normal pregnancy. 
But, should any mechanical impediment prevent its further expansion 
in the direction of the abdomen, or should any other cause induce its 
prolonged sojourn in the pelvis, the pressure which is exercised upon 
the bladder and rectum interferes seriously with their functions, and 
the case goes on, with great suffering to the patient, until nature relieves 
herself by expelling prematurely the contents of the womb. Those 
instances in which it is reported that pregnancy went on uninterruptedly, 
must, we presume, have been cases in which the cavity of the pelvis 
presented very unusual dimensions. In some of them the uterus pro- 
jected partially, but the most extraordinary of all, are those in which 
prolapsus has been complete, the gravid uterus lying in the form of a 
huge tumor between the thighs of the mother ; and, incredible though 
it may seem, it has been asserted that under such circumstances, preg- 
nancy has reached its normal termination without any special danger 
either to mother or child. The usual result is that abortion occurs 
before the end of the fifth month, as in cases narrated by Levret, 
Capuron, and others. The treatment will consist mainly in careful 
attention to the functions of the bladder and rectum, and in watching 
the progress of the case. When the prolapse has preceded pregnancy, 
and circumstances point to the possibility of an occurrence such as we 
are now considering, we should watch the case carefully as the period 
approaches at which the uterus should rise above the brim, and, if 
necessary, afford it some aid by careful manipulation, as was done by 
Scanzoni in two cases. Should the organ appear externally, similar 
efforts should be made, failing which, it must be supported by an ex- 
ternal bandage. But, so soon as dangerous symptoms manifest them- 
selves, or the bowels or bladder are so obstructed as to render defeca- 
tion or micturition impossible, our course of procedure is clearly to act 
promptly, in such manner as may seem most judicious, with a view to 
the immediate expulsion of the contents of the uterus, for to allow such 
a pregnancy to continue would be to compromise the life of the mother 
as well as that of the child. 

Anteversion and Anteflexion. — These forms of displacement are of 
rare occurrence during the early months of pregnancy. This is what 
an observation of the anatomical relation which the organ bears to the 
j)elvic walls would have led us to anticipate ; and, as Kiwisch has well 
observed, any such tendency which might exist is obviated further by 
pressure, directed upwards against the fundus by distension of the 
bladder, and downwards against the vaginal portion by repletion of the 
rectum. Cases have, however, been occasionally observed, giving rise 
to symptoms indicating obstruction to the action of the bowels and 
bladder. The digital examination which such symptoms suggest 
reveals at once the nature of the case, the cervix being high in the 



246 DISEASES OF PREGNANCY. [CHAP. 

hollow of the sacrum, while the fundus forms a rounded tumor in the 
roof of the vagina in the direction of the bladder. In such a case, the 
patient should be directed to lie on her back as much as possible; and, 
when the period arrives at which the uterus no longer finds accommo- 
dation within the pelvis, the fundus will rise upwards, and will thus 
spontaneously relieve any uneasiness to which the displacement may 
have given rise. This is the natural issue of such a case; but it is 
quite possible that, in some instances, the dislocation may be reduced 
by careful pressure upwards of the fundus by the finger, but this should 
only be attempted should the severity of the symptoms warrant any 
interference. In the latter months of pregnancy, anteversion is of 
more frequent occurrence, and is then associated with the phenomenon 
of pendulous abdomen. It is observed almost always in the case of 
multipara, in whom the abdominal walls have been subjected to 
repeated distension, and in those, it is said, in whom the inclination 
of the pelvis is greater than usual. In direct proportion to the degree 
of displacement is the amount of pressure to which the bladder is sub- 
jected, and, consequently, the degree of discomfort to which it gives 
rise by impeding the flow of urine. In some instances, the abdominal 
wall not only projects forwards, but hangs downwards, and to those 
cases the term anteflexion is more applicable than anteversion, as the 
axis of the uterus is then bent in a greater or less degree. In extreme 
cases, the walls of the abdomen have been observed to hang down as 
far as the knees, but it seems likely that in most of these there is an actual 
hernia of the womb, owing to a separation of the recti muscles, between 
which it protrudes. This form of displacement may, as we shall have 
occasion hereafter to observe, cause difficulty in the process of parturi- 
tion, by misdirecting the expulsive force ; but, in every case, the treat- 
ment is the same, and consists in an endeavor to raise the fundus by a 
bandage, supplying in this way the support which the abdominal wall 
should afford ; and, in addition, attending to the function of the bladder, 
remembering always that the greater the displacement of the womb, 
the greater is the corresponding elongation of the bladder. That organ, 
indeed, in some cases, loses all traces of a spheroidal form, and assumes 
the shape of an elongated pouch, which is bent over the symphysis, 
and which, therefore, can only be conveniently emptied by the use of a 
long elastic catheter. 

Retroversion and Retroflexion of the gravid uterus are much more 
dangerous both to mother and child than displacements in the contrary 
direction. The distinction between the two varieties depends simply, 
as the names imply, upon whether the long axis of the uterus is bent 
or straight, and in each the fundus of the uterus occupies more or less 
completely the recto-vaginal pouch of the peritoneum. We believe, 
however, that the distinction which is usually drawn between retro- 
version and retroflexion, whether occurring in the unimpregnated state 
or during gestation, is more apparent than real. The majority of cases 
will be found in fact, on careful examination, to be neither exactly the 
one nor the other, but a condition intermediate between the two, in 
which the axis of the uterus is neither straight, nor abruptly bent at 



XIV.] RETROVERSION. 247 

the os internum like the neck of a retort, but forms the arc of a circle, 
the imaginary centre of which varies very greatly. 

As — although, probably, in a very limited number of cases — im- 
pregnation may take place of an ovum contained in a womb, the fun- 
dus of which is displaced backwards, it is proper to notice here briefly 
the causes which have been assumed, and to a certain extent have been 
demonstrated, to lead originally to this displacement. It has been 
supposed, and we believe with good reason, that there is often an un- 
usual mobility of the uterus in the direction which leads to the dis- 
placement we are now considering. This is due to a morbid relaxation 
and lengthening of the round ligaments and vesico-uterine folds, which 
thus admit in the first instance of a movement of the fundus back- 
wards, encouraged by repletion of the bladder, and still more by over- 
distension, arising either from carelessness or from any other cause. 1 
The effect of the combined action of these two causes is to induce a 
certain amount of displacement, which other circumstances may tend to 
aggravate or complete. While the uterus is in its normal position, it 
is impossible that distension of the rectum can cause retroversion, but 
so soon as the causes above detailed, or others to be mentioned presently, 
have acted so far as to press the fundus backwards towards the promon- 
tory of the sacrum, then this new force comes into play, the fecal masses, 
as they descend, gradually forcing the fundus further and further down 
into the pouch of Douglas, until a marked case of retroversion or re- 
troflexion is the result. The other causes alluded to as auxiliary 
forces, are the downward pressure exercised by the abdominal viscera, 
and the existence of fibroid growths in the posterior uterine wall. At 
any stage impregnation is possible, and it is easy to understand how, 
in such a case, a comparatively slight displacement may be converted 
into one in which the fundus fills the hollow of the sacrum, and may 
actually reach as far down as the coccyx. Before long, however, the 
limited space, within which, in this position of the uterus, the devel- 
opment of that organ goes on, becomes filled, and the pressure upon the 
bladder and rectum calls immediate attention to the case. An exami- 
nation discloses the altered anatomical relations of the parts. The os 
and cervix will generally be found about the level of the subpubic 
angle, or somewhat above it; while, behind this, and about the same 

1 With a view to the elucidation of the subject, Scanzoni made a series of most 
interesting observations both in the living and the dead. He found, in the first 
place, that distension of the bladder always caused a certain amount of displacement 
backwards of the fundus. " We found,'' he says, " when we artificially filled the 
bladder in dead bodies, that the duplicatures of the peritoneum passing from the 
uterus to the bladder, stretched themselves in direct proportion to the distension of 
the bladder, so that when the bladder was filled and distended as far as possible, 
this stretching reached to such an extent that it was impossible, without considera- 
ble effort, to force the fundus of the uterus backwards for more than a few lines, as 
its attachment to the posterior wall of the bladder was much more firm than when 
that viscus was empty. A very different result ensued when we, in the first in- 
stance, cut the round ligaments and the peritoneal duplicatures above alluded to, 
and then filled the bladder. In this case, by a moderate distension, the fundus uteri 
was strongly displaced backwards, and the vaginal portion forwards, so that it de- 
pended upon our will, by the injection of a greater or less quantity of fluid into the 
bladder, to induce a higher or lower grade of retroversion." — Lehrbuch der Geburts- 
hilfe. 



248 



DISEASES OF PREGNANCY. 



[CHAP. 



level, a firm rounded tumor is felt, apparently occupying the recto- 
vaginal pouch, and pressing forwards the posterior wall of the vagina. 
(Fig. 95.) On examination by the rectum, — into which two fingers 
are to be passed as high as possible, — the same tumor is felt through 
the anterior wall, but in this method of observation, considerable diffi- 
culty will often be experienced in passing the finger, owing to the great 
pressure to which the bowel is subjected. Backward displacement of 
the gravid womb has generally been observed in the third or fourth 
month of pregnancy, but cases are recorded by Smell ie, Bartlett, and 



Fig. 95. 




Retroflexion of the womb about the 16th week. (Schultze.) 



others, in which it was observed as late as the fifth or even the seventh 
month. It is more than likely, however, that, in those instances, what 
Scanzoni describes as partial retroflexion was mistaken for complete 
dislocation of the organ. The partial retroflexion here referred to 
would be more accurately described as a peculiarity in the shape of the 
uterus, in consequence of which its posterior wall forms a tumor which, 
owing to some peculiarity in the position of the child, projects into the 
recto-vaginal pouch, and thus resembles an ordinary case. Assuming 
that this does actually take place, the occurrence is possible at a much 
more advanced period of pregnancy, when the development upwards of 
the remainder of the uterus would probably enable us, without much 
difficulty, to recognize the nature of the case. 

Of much more frequent occurrence than that which we have just 
described, and which we may call the chronic form, is the acute retro- 
version of pregnancy. (Fig. 96.) The affection occurs suddenly, but 
it is most likely that there is a pre-existing minor degree of displace- 
ment, which gives rise to a further and sudden change in the position 



XIV.] 



ACUTE RETROVERSION. 



249 



of the womb, sufficient to cause complete retroversion. Immediately 
upon the occurrence of this dislocation, or within a very short period, 
the woman complains of severe dragging pain, which is accompanied 
by a new sensation, as of a foreign body in the pelvis. This gives rise 
to painful and fruitless expulsive efforts, with increase of the pain 

Fig. 96. 




Retroversion about the 12th week. (Schultze.) 



around the entire pelvis, and great difficulty in emptying the bladder 
and the rectum. These symptoms are usually attended with faintness, 
nausea, and vomiting, and other general symptoms of even greater 
severity ; and, unless the reposition of the organ be speedily effected, 
this state of matters gives rise to complete retention of urine and ob- 
struction of the bowels, which may, in their progress, result in rupture 
of the bladder, stercoraceous vomiting, ileus, and such symptoms as 
precede a fatal result. In many cases, — perhaps in most of those in 
which the incarceration of the organ is prolonged, — there is congestion 
and thickening of the uterine walls, and this may sometimes amount 
to actual inflammation of the organ, which becomes exquisitely tender, 
and thus aggravates greatly the sufferings of the patient. 

The natural termination of a case such as this involves great risk to 
the mother, and almost certain death to the child. For, although in 
its further development the womb may possibly take an upward direc- 
tion, and the symptoms be thus spontaneously relieved (and such cases 
are on record), the usual result unfortunately is, that the increase of 
the uterus gives rise to the more serious symptoms above detailed, 
which can only be relieved by arrest of development, or by expulsion 
of the foetus. Nothing can, therefore, be more obvious than the neces- 
sity which exists for prompt action in the w r ay of treatment. Should 



250 DISEASES OF PREGNANCY. [CHAP. 

the congestion of the womb be marked, benefit will be derived in the 
first instance from the use of warm baths and injections, and local or 
even general bloodletting ; and, when these measures have had time 
to act, attempts are then to be made to effect the reposition of the 
organ, taking care, of course, in the first place, that the bladder and 
rectum have been thoroughly emptied. 

The woman having been placed in the ordinary midwifery position, 
with the nates projecting over the edge of the bed, or on her elbows and 
knees, the index and middle fingers, previously well oiled, are introduced 
into the rectum, so as to bear against the tumor, 1 and an effort is then 
to be made by means of steady pressure in the axis of the brim, to push 
the fundus beyond the promontory of the sacrum. It will be observed, 
should it be found possible to displace the fundus to any extent, that 
the movement takes place not directly towards the promontory, but 
rather towards the sacro-iliac synchondrosis of either side; and, as we 
cannot tell beforehand to which side it will incline, although the prob- 
abilities are in favor of the right, we must, in the first instance, push 
directly upwards. But, should the fundus obviously tend to move in 
the direction of one sacro-iliac joint in preference to the other, the 
direction of the pressure must then be altered, in order to accommodate 
it to the tendency thus exhibited. If the compression of the rectum 
is such as to prevent the introduction of the fingers to a proper height, 
Kiwisch suggests that we should substitute the handle of a silver spoon 
or of a sound for the finger. Should a first attempt at reposition fail, 
we may pause and endeavor, by means of repeated injections, cold 
or warm, still further to reduce, if possible, the intumescence of the 
womb. The patient may then be brought fully under the influence of 
chloroform, and the attempt renewed in a different posture, when, in 
many instances, the dislocation will be happily reduced, the womb 
being occasionally restored to its normal position, as in the case of 
its inversion, with a snap or jerk. Should difficulty occur in the intro- 
duction of the finger into the rectum, it will be proper to make an 
attempt by the vagina, although in this case, as a little reflection will 
show, the attempt will be made at a greater mechanical disadvantage 
than when the rectum is selected. Failing all these methods, we may 
attempt to dislodge the fundus by the introduction, as high as is pos- 
sible, into the rectum of an elongated air-bag, such as those invented 
by Barnes for dilating the os and cervix in inducing premature labor. 
These bags have a long tube fitted at the end with a stopcock, and 
through this the injection, either of air or of water, causes a graduated 
pressure which acts continuously, and at the same time effectively, upon 
the displaced fundus, so as gradually to effect its reposition. 

All attempts at reduction having failed, the best mode of procedure 
is to adopt only such measures as are necessary for the relief of the 
bladder and the rectum, so long as the symptoms are not so severe as 
to call for immediate action. But should the emptying of the bladder 

1 Scanzoni recommends that the thumb of the same hand should be introduced 
into the vagina, mainly with the object of elevating the perineum, and thus allow- 
ing the examining fingers to pass higher. 



XIV.] OBLIQUE DISPLACEMENTS. 251 

become impossible, or should any other symptom develop itself which 
may be held to imply that the life of the mother is in imminent danger, 
there then remains for us no resource but to imitate nature, and to 
induce, without delay, the premature expulsion of the foetus. Of the 
many methods by means of which, as we shall have occasion again to 
observe, it is possible to induce premature labor, that which is most 
applicable to the present case is the rupture of the membranes. For, 
the immediate effect, which is thus produced by the sudden evacuation 
of the liquor amnii, is to reduce the diameter of the uterus, and thus 
to afford partial relief during the period wdiich intervenes between the 
operation and the commencement of uterine action. It is, however, by 
no means an easy matter in every case to effect this rupture, more espe- 
cially when the os is tilted up behind the symphysis, and is only reached 
with difficulty, and it may be found necessary on that account to intro- 
duce a catheter, with an opening at the extremity, through which a wire 
may be passed, and having reached the membranes, to thrust the wire 
through and thus effect our purpose. But it may happen, unfortunately, 
that the os is displaced upwards to such an extent that it is impossible 
to reach it, or at least to pass anything through it, and in such circum- 
stances we have no alternative, if the life of the mother is in obvious 
danger, but to puncture that portion of the uterine wall which lies 
lowest, and thus give vent to the amnionic fluid, and afford relief to the 
patient. It is of course safer, under such circumstances, to puncture 
from the vagina than from the rectum, but the latter operation has been 
successfully performed, effusion into the peritoneal cavity having been 
prevented, by leaving the canula in situ until the risk of further effusion 
had passed. The uterus being thus relieved of its fluid contents, may 
now be replaced without much difficulty, unless adhesions should chance 
to have occurred, and then awakened expulsive effort will speedily 
relieve the organ of its solid contents. Where reposition of the uterus 
has been successfully effected, labor may go on without any further 
accident or hindrance, but in some few instances it would seem that a 
tendency to relapse remains. This must therefore be guarded against, 
by insisting upon strict rest on the side, and, by the frequent use of 
the catheter and enemata, to prevent such mechanical pressure from 
the bladder and rectum as might encourage a recurrence of the dis- 
placement. 

Oblique Displacements of the uterus have been insisted upon by some 
writers as exercising an important influence on the progress of preg- 
nancy. We know already that the long axis of the gravid uterus does 
not correspond with the middle line of the body. It is quite possible, 
therefore, that when this normal obliquity is exaggerated, the os may, 
for a time, be prevented from dilating by the altered axis of the ex- 
pulsive force. Such displacements, however, seem to have had their 
origin in a great measure in the imagination of those who have sought 
to reduce the art of midwifery to a series of geometrical propositions, 
and are certainly not of sufficient practical importance to require more 
particular attention. 

In addition to the diseases of pregnancy which we have described, 



252 LABOR AND ITS PHENOMENA. [CHAP. 

there are others, chiefly constitutional, which exist both during and 
after labor, the consideration of which we shall, therefore, in the mean- 
time, defer. 



CHAPTER XV. 

LABOK AND ITS PHENOMENA. 

CAUSES OF LABOR — MATURITY: ANTAGONISM BETWEEN CURTAIN GROUPS OF 
UTERINE FIBRES: BROWN-SEQUARD'S THEORY: LABOR COINCIDENT WITH 
THE TENTH MENSTRUAL PERIOD — FORCES BY WHICH DELIVERY IS EFFECTED: 
NERVI -MOTOR FUNCTIONS OF THE UTERUS: EFFECT OF EMOTIONAL CAUSES: 
REFLEX FUNCTION OF THE SPINAL CORD: PERISTALTIC ACTION: AUXILIARY 
FORCE IN THE MUSCLES OF EXPIRATION — STAGES OF LABOR — PREPARATORY 
STAGE — FIRST STAGE: LABOR PAINS; THEIR EFFECTS ON THE MATERNAL 
PULSE AND ON THE UTERINE SOUFFLE: FALSE PAINS: MECHANISM OF THE 
DILATATION OF THE OS ; THE BAG OF WATERS ; EFFECT OF LONGITUDINAL 
FIBRES: TERMINATION OF FIRST STAGE IN RUPTURE OF MEMBRANES : RIGOR: 
SHOW — SECOND STAGE: CHANGE IN CHARACTER OF THE PAINS : THE "CAPUT 
SUCCEDANEUM :" ACTION OF VOLUNTARY MUSCLES: DILATATION OF THE 
PERINEUM: BIRTH OF THE HEAD AND TRUNK — THIRD STAGE: "DOLORES 
CRUENTI:" SEPARATION AND EXPULSION OF THE PLACENTA; MECHANISM OF 
THIS. 

The first point which, in considering the subject of labor, attracts 
our notice, is one which has given rise to many interesting physiologi- 
cal speculations. We refer to the causes which lead to the occurrence 
of delivery, in almost all cases in which the course of pregnancy is 
undisturbed, at a certain fixed period, calculated from the assumed 
date of conception. In ancient times, the idea prevailed that the foetus 
was itself the principal agent in effecting its birth, breaking the mem- 
branes, and opening up the womb in its efforts to reach the external 
world, after the same fashion as the chick when escaping from the 
thraldom of the egg. The advance of physiological science generally, 
and more especially the discovery and demonstration of the contrac- 
tility and muscular structure of the uterus, while they showed clearly 
enough how erroneous this opinion of the ancients was, did not dis- 
close, and as yet have not clearly revealed, what is the determining 
cause of uterine contractions at the period alluded to. There exists, 
say some, a natural antagonism between the muscular fibres of the 
body of the uterus and those of the cervix ; and, so long as the oblit- 
eration of the cervix is not effected by the progress of development 
towards the end of gestation, the tonic contraction of the fibres of the 
body is not sufficient to overcome the resistance offered by the cervix. 
But, so soon as the process of dilatation has entirely invaded the cer- 
vix, — a change which is only complete with the termination of preg- 



XV.] CAUSES OF LABOR. 253 

nancy, — the fibres of the body for the first time prevail, and the con- 
tractions assuming a rhythmical method of action, gradually increase 
in intensity until they result in real labor pains. Others, and among 
them Dubois, recognizing the exact analogy which subsists, in regard 
to the distribution of muscular fibres and nerves, between the uterus 
and the other hollow viscera, and assuming that in the uterus, as in 
the rectum and bladder, contraction may be awakened by irritation of 
the cervix (to which alone, as we have already seen, the nerves of 
animal life are supposed to have access), believe that in these facts the 
secret is revealed. They hold that complete obliteration of the cervix 
involves the highest grade of physiological development to which its 
fibres can attain, and that the sphincter fibres are then for the first 
time fully susceptible of external influences, communicated to them 
through cerebrospinal nerves. And they conclude that, in this manner, 
the first excitation reaches the cervix, and thus contraction of the whole 
organ ensues. 

A most ingenious theory has been founded by M. Brown-Sequard on 
the result of certain experiments which he performed by tying the 
trachea of pregnant animals, in whom he had previously destroyed the 
lower portion of the spinal cord. The immediate result of the apncea 
thus artificially induced, was the occurrence of uterine contractions, 
which disappeared on relaxing the ligature, and returned again on 
repeating the experiment. This is due, says the experimenter, to the 
contact of venous blood with the muscular fibres, the irritability of 
which is highly exalted during pregnancy. He explains the earliest 
uterine contractions on the same principle. The large size of the uterine 
sinuses insures the presence in the substance of the uterus of a large 
quantity of venous blood, and so soon as the muscular fibre reaches, at 
the termination of pregnancy, its highest point both of irritability and 
of development, it becomes for the first time excited to contraction. 
The immediate result of this is to empty, in a great measure, the sinuses 
of blood ; but so soon as the rhythmical relaxation occurs, the venous 
blood again gains access to the irritable fibres, and anew excites them 
to contraction. 

Whatever view we may be inclined to assume in reference to the 
cause of labor, there can be no doubt that it is coincident with the 
maturity of the foetus. Gradual relaxation of the anatomical connec- 
tions between the uterus and the ovum, is another undoubted phenom- 
enon w . £ icli immediately precedes birth, and it was in this that Simpson 
believed the determining cause to reside. And, finally, Dr. Tyler Smith 
has suggested — and argues with great ability in favor of the theory — 
that the cause of labor is to be found in the ovary. " It is allowed by 
all observers," says Dr. Smith, "that labor has a tendency to occur, 
and does occur, in a great proportion of cases, in the fortieth week from 
the last menstruation ; and it is equally allowed that impregnation is 
generally effected just after the catamenial period. It is also made 
out by the record of a considerable number of cases in which a single 
coitus occurred, that gestation lasts, on an average, about 275 days 
from the actual date of impregnation. These dates make the average 
duration of pregnancy approach 280 days from the last catamenial 



254 LABOR AND ITS PHENOMENA. [CHAP. 

period, and the oecnrrence of parturition, is on the average, very nearly 
a multiple of a single catamenial period." We confess that the argu- 
ments which this author advances in support of his theory, seem to us 
in a great measure to warrant the conclusion at which he has arrived ; 
but, while we admit that it is probable that a presiding influence 
springs from the ovary at the period of the natural menstrual molimen, 
we by no means wish to commit ourselves to the opinion that it is the 
sole cause. 

Whatever we may assume the cause of labor to be, the immediate 
effect of its operation is to rouse the latent energy of certain Forces, 
by means of whose active co-operation the delivery of the woman is 
effected. The prime force, to which the others are merely subsidiary, 
is, as is well known, the contraction of the muscular fibres of which the 
uterus is, to such a large extent, composed. That these contractions 
are of very considerable power, is proved, not merely by the resultant 
of the force, as shown in the expulsion of the foetus, but also palpably 
to the senses by the contraction which may be seen and felt through 
the abdominal walls, and by the effect which is produced on the hand 
when introduced into the uterine cavity. Dr. Matthews Duncan has 
computed this force as equivalent to a pressure of 3 lbs. on the square 
inch. 

In considering the Nervi-motor functions of the uterus, we observe, 
in the first place, that volition exercises no direct influence whatever 
on the contraction of the uterine muscular fibre ; although, as we shall 
see, it presides over what will be afterwards described as the auxiliary 
forces. In cases of cerebral paralysis, and when the action of the will 
has been completely suspended by chloroform, we find that uterine 
contractions are quite undisturbed. Nay, stranger still, we know that, 
in some instances, contractions may occur after death, giving rise to 
post-mortem delivery. There are cases, at least, in which this phenom- 
enon is due to actual contraction of the fibres ; but we must be careful 
to draw a distinction between these and cases of expulsion, which have 
occurred some days after death, and which have been found to be due 
either to rigor mortis, or to pressure from the development of gas in the 
process of putrefaction — a condition which gives rise to other strange 
phenomena familiar to the student of medical jurisprudence. 

Certain emotional causes produce an effect on the uterine contractions 
which it is not easy to account for. Few occurrences are more familiar 
to the accoucheur than the effect which his arrival frequently produces 
upon the progress of labor, by causing a complete temporary cessation 
of all uterine effort* On the other hand, sudden mental emotion of 
any kind may, by augmenting the force and frequency of the expulsive 
action, sometimes influence the progress of labor in a marked degree; 
and this has been observed to occur upon the threat of using instruments, 
or upon the exhibition of the forceps. Causes, then, which, being psy- 
chical, have their origin in the cerebrum, may act either by increasing 
or by arresting uterine effort. 

The spinal marrow exercises upon the uterus a very obvious and 
important influence. There is, in the first place, a direct or centric 
action, in which the motor nerves are excited by a communication 



XV.] NERVI-M0T0R FUNCTIONS OF THE UTERUS. 255 

starting from the nervous centre ; and it is in this way that ergot and 
other oxy toxics act, being conveyed to the cord by the circulation, and 
there producing an effect which is transmitted to the uterus, where it 
takes the form of muscular action. In this manner, too, many diseased 
conditions of the blood produce an effect, as is well known, by acting 
on the cord, and giving rise to different varieties of puerperal eclampsia ; 
and in this way even plethora, or anaemia, may exercise an influence on 
the dynamic force of the womb. But of much greater importance, and 
of higher physiological interest, is the diastaltic, or reflex function of 
the cord, which chiefly presides over the motor functions of the uterus. 
One of the most familiar instances of this is the uterine contraction 
which ensues upon the irritation of the nipple by the contact of the 
child. The impression is, in this case, conducted to the spinal centre, 
and being thence reflected to the uterus, forthwith acts upon its con- 
tractile fibres ; indeed, so constant is this occurrence, that it is admitted 
in practice as a valid reason for putting the child to the breast at an 
early period after delivery. A similar effect may be produced, although 
with less certainty, by an irritation of a similar kind starting from the 
stomach, rectum, or any other part of the alimentary canal; from the 
ovary, or from any structure in the immediate vicinity of the uterus; 
and, finally, from the direct irritation of the organ itself, which may 
be effected in various ways, the most reliable of which is irritation of 
the os and cervix, or of the internal surface in the case of haemorrhage. 
The very extensive nervous sympathy which thus exists between the 
uterus and so many distant parts, shows pretty clearly that its nervous 
functions are, during pregnancy and the puerperal state, greatly in- 
creased. What is known, up to the present titne, in reference to the 
uterine nerves, is by no means very satisfactory ; but the result of most 
modern investigations in regard to these nerves, which are only to be 
traced with the greatest difficulty, seems to confirm the view originally 
adopted by Dr. R. Lee, that they undergo, during pregnancy, con- 
siderable enlargement, — an enlargement, however, which appears to 
have its seat mainly in the neurilemma. This subject is one which has 
given rise to a deal of acrimonious discussion, and is still beset with 
difficulties which have only been partially overcome. It was stated 
in a former chapter that twigs of the sacral nerves, passing to the os 
and cervix, constitute the channel of communication between the cord 
and the uterus, but that the rest of the nerves are derived from the 
ganglionic system. When, therefore, nervous force is reflected upon 
the uterus from the cord, it passes by the nerves in question, and 
reaches in the first instance the cervix and os. In this situation plex- 
uses are found, to the formation of which the spinal and ganglionic 
systems contribute, and through these the force is transmitted to ter- 
minal fibres in the body of the organ, where it excites immediate and 
effective contraction. 

It is well known that the hollow viscera, which are supplied in 
whole or in part by the ganglionic nerves, contract, when irritated, after 
a fashion peculiar to such structures. The contraction, instead of being 
limited to the immediate vicinity of the point of irritation, is propa- 
gated in a definite direction in rhythmical waves, successive groups of 



256 LABOR AND ITS PHENOMENA. [CHAP. 

fibres being thus excited so as to constitute the phenomenon commonly 
known as peristaltic action. The uterus forms no exception to this 
general law, and its peristaltic or ganglionic motor action was observed 
and described by Harvey and William Hunter, and by every physiol- 
ogist of note since their day. The manner in which peristaltic uterine 
action occurs is, as Wigand has taught, in so far as the contractions of 
labor are concerned, as follows : The earliest contractions always take 
place at the neck, which grows tense. From this point, the vermicular 
action extends gradually upwards in the direction of the fundus, from 
whence it again returns towards the os, obvious mechanical advantages, 
of which we shall speak presently, being attendant upon this method 
of action. Uterine expulsive action is thus a composite force, which 
is partly diastaltic and partly peristaltic. Physiologists have sought, 
by many ingenious experiments on the lower animals, to ascertain what 
is the precise share which is to be attributed to the reflex function of 
the spinal cord in producing the phenomena of labor. These experi- 
ments have usually taken the form of section of the spinal cord at a 
certain level, or destruction of the lower part of the cord ; and it has 
been found that the latter procedure has produced the most decided 
effect in arresting uterine action. In most of these cases, however, it 
would seem that the peristaltic action remained, and that there was 
still sufficient expulsive force left to effect delivery. In some cases, 
it would almost seem as if destruction of the lower part of the cord 
put an end to all uterine action, but there are obvious sources of fallacy 
connected with such a method of investigation which render it neces- 
sary to exercise great caution before coining to a positive conclusion. 
It is, indeed, a- very difficult question, and one which still remains for 
solution, whether or not, all connection with the nervous system of 
animal life being cut off, peristaltic contraction remains possible ; for 
it must not be forgotten that, however thoroughly we may destroy the 
lower half of the spinal cord, there still remains, in the connections 
which subsist between the sympathetic system and the upper part of 
the cord, a possible, though circuitous route, through which the impor- 
tant influence of the cord may still, although more feebly, be exercised. 
In making the assertion that the will has no influence directly upon 
the contraction of the womb, we must not be understood as implying 
that the will exercises no influence on the progress of labor. For we 
shall see immediately that there is a stage of labor at which the volun- 
tary muscles are brought into play as an auxiliary force, and that the 
woman instinctively avails herself of their aid. The diaphragm and 
the abdominal muscles are the chief agents of this new power, and 
everything therefore which gives a fixed point for the efficient action of 
the semuscles, indirectly gives great assistance in the progress of labor. 
It is this which causes a woman instinctively to arrest respiration, in 
order to admit of the efficient action of the diaphragm, and for the 
same reason she will eagerly employ the means which are afforded her, 
by towels tied to the bedpost, or footstools in the bed, to fix the trunk 
so as to bring the whole power of the expiratory muscles into play. 
A minor degree of voluntary expulsive effort, which is in all respects 
similar, is that which attends difficult defecation. Haller attributed 



XV.] STAGES OF LABOR. 257 

to the abdominal muscles the chief share of the expulsive efforts, but 
that this is obviously wrong is shown by the fact that in feeble wo- 
men, in whom the voluntary muscular system is very poorly developed, 
the delivery is not only effected as easily as in others, but actually in 
many instances, with greater ease ; and, moreover, complete anaes- 
thesia, which has a most marked effect on the voluntary muscles, 
scarcely affects in any marked degree the progress of delivery. An- 
other auxiliary force exists, in an advanced stage of labor, in the 
action of the muscles which constitute the floor of the pelvis, and in 
the contraction of the muscular fibres which enter into the composition 
of the vaginal walls. In the lower animals, as is well known, the 
comparatively feeble contractile efforts of the uterine cornua bring the 
young successively to the os uteri, when, powerful and violent propul- 
sive efforts being awakened in the vagina, they are promptly expelled. 
In those animals, therefore, we may look upon the vagina rather than 
the uterus as the great organ of parturition. What occurs in the human 
species is precisely similar, only that here the vaginal contraction is 
subordinate to the uterine, while in rabbits and such like the converse 
is the case. That the vaginal expulsive force is by no means incon- 
siderable is shown by the manner in which the placenta is expelled, 
and still more, by what involves a more powerful muscular effort, — the 
expulsion of the head in cases of presentation of the breech. In regard 
to the share which is taken by the muscles at the floor of the pelvis, 
this, too, is in all probability considerable, and constitutes, no doubt, 
the "reflected force" of which Solayres de Renhac speaks in his ad- 
mirable essay. 

The Stages of Labor. — Writers, in considering the physiological 
phenomena of labor, have uniformly adopted the plan of dividing its 
progress into various stages. Some have multiplied these stages to an 
extent which is absurd, as the subject is thus rendered more perplexing 
instead of being made easy of comprehension to the student. The 
familiar classification of Desormeaux, according to which labor is 
divided into three stages, is that which is adopted here. 

1st. From the beginning of labor until complete dilatation of the os 
uteri is effected. 

2d. From full dilatation of the os till the birth of the child. 

3d. The complete separation and expulsion of the placenta. 

In considering the First Stage of labor, some little difficulty is 
experienced in determining the exact moment from which labor is to 
be dated. Long before symptoms of actual labor manifest themselves, 
certain preliminary processes are gone through, and to this some 
writers have with propriety attached the name of the Preparatory 
Stage. The falling down of the womb, which occurs in the last weeks 
of pregnancy, may be mentioned as perhaps the earliest of those changes. 
This, as has already been stated, is usually attended with a marked 
relief of such symptoms as arise from pressure upwards; but these are 
often replaced by such as are the result of pressure in the contrary 
direction, so that dysuria and irritation of the lower bowel now become 
familiar symptoms. If an examination is made at this period, the 
head will be found to have descended in the pelvis, and the condition 

17 



258 LABOR AND ITS PHENOMENA. [CHAP. 

of the os characteristic of the stage of pregnancy will at the same 
time be disclosed. The ligaments also of the pelvis become more 
relaxed and elastic, and the articulations somewhat less firm. The first 
contractions of the womb at the commencement of labor are either 
painless, or accompanied with discomfort so slight, as scarcely to attract 
the attention of the patient. Even thus early, however, the contrac- 
tions may be perceived by the hand of the accoucheur, if he make 
an examination through the abdominal walls ; and they are often 
accompanied with such an amount of pain as to lead a woman who has 
previously borne children to look for the speedy occurrence of labor. 
It is by no means a rare occurrence for this class of pains to recur again 
and again, night after night, keeping the patient in a constant state of 
expectancy and apprehension. Usually, however, the period soon 
arrives Avhen the pains become more severe, and return at regular 
periodical intervals, when the contractions, as observed through the 
abdominal walls, will be found to be much firmer than those of the 
earlier period. 

A Pain in midwifery is used as synonymous with the expression 
"contraction," the one symptom depending directly upon the other. 
When, at the commencement of labor, the uterus is thrown into con- 
traction, the cervix being, as we have seen, first affected, and then the 
fundus, the muscular fibres, after remaining in a state of contraction 
for a brief period, relax, — as is usually the case in non-striated muscle, 
it being only exceptionally capable of sustained effort. During the 
whole period of a healthy labor, therefore, pain and pause alternate, the 
former being at first of short duration, and coming on at long intervals; 
but as the case progresses, the pains become longer and more severe, 
and the pauses shorter and shorter, until, at the final effort, one pain 
succeeds another with such violence and rapidity that the periods of 
rest or pause are almost obliterated. When a pain comes on, it may 
in many cases be observed that the fundus, which, is usually displaced 
to the right, moves toward the middle line, so as to bring the expul- 
sive force to act in the direction in which it can be most efficiently 
employed. If we, at this stage, make a vaginal examination, we find, 
in primipara?, that the os and .cervix are so far obliterated, that the 
margin of the former is a thin, circular, and almost membranous ring, 
which represents that portion of the uterus. Against this apparently 
unyielding ring, the membranes are firmly pressed during the continu- 
ance of a pain ; and, as the amnionic fluid necessarily takes the direction 
in which there is least resistance, it is found that at this moment the 
difficulty of reaching the presenting part is increased by the augmen- 
tation in the quantity of the imposed stratum of liquid, and by the 
tension to which this gives rise. Soon, however, the rigid margin 
becomes softer and more tumid, a condition which, in pluriparse, exists 
from the first, and the os yields slowly under the influence of successive 
pains, so that we are able during the intervals of perfect rest to hook 
the finger into the os, and to feel distinctly the presenting part. 

It is interesting to observe the effect which is produced on the 
mother's pulse by the occurrence of a pain. If, placing a finger upon 
it, we note, during an interval of rest, the number of beats, and con- 



XV.] EFFECT OF PAINS ON THE PULSE. 259 

tinue the observation, we shall find that, with the commencement of 
the pain, its frequency is increased, and that, continuing to rise, it 
attains its maximum along with the pain ; while with its subsidence, 
the pulse falls, and on its complete cessation is found to have returned 
to its original rate. This observation, as Hohl points out, may be use- 
fully employed as a test to gauge the efficiency of the pains, for the 
more marked and rhythmical this variation of the pulse, the more 
effective is the pain which it at once accompanies and indicates. " When, 
however," he says, "the rapidity of the beats subsides before approach- 
ing the maximum, the pain is too weak ; or when the rapidity rises by 
sudden starts, the pain is a hurried one, and in either case its effect will 
be imperfect." He assumes that, in an efficient pain of average dura- 
tion, the increase and diminution of the pulse for each quarter of a 
minute may be put down as follows : 

18. 18. 20. 22 : 24. 24. 22. 18. 

It would thus appear that the frequency of the maternal pulse attains 
its maximum during the first half of the second minute: but it must be 
understood, in making observations, based upon this, that it applies to 
average pains only, and that towards the termination of labor, when 
the systemic excitement is intense, the pulse from that cause is often 
so accelerated that any observation of the kind is impossible. If aus- 
cultation be practiced during the pains, we often find that the foetal 
pulsations are somewhat accelerated, but the effect of a pain tends 
rather to obstruct than to facilitate the observation of the feetal heart. 
The uterine souffle, however, undergoes, almost invariably, marked 
modifications. The situation having been ascertained at which that 
sound may most distinctly be made out, auscultation is sustained during 
the continuance of a pain, or of a succession of pains, when the follow- 
ing modifications are observed. The approach of a pain is heralded by 
a rushing sound, which may indicate muscular action, movement of the 
amnionic fluid, or movement of the child. Along with this, there is a 
marked increase in the distinctness of the souffle, which is raised in 
tone and in pitch, and may even become vibrating or musical. Up to 
a certain point this increases in intensity; but, as the pain approaches 
its acme, the sound becomes as it were more and more distant, and then 
— when the moment of greatest contraction is attained — very faint, or 
altogether inaudible ; while, as the pain goes off, it passes again through 
those changes in an inverted order, until the tone proper to the period 
of rest is restored. 

We must be prepared in every case for the occurrence of what are 
called false pains, in which, although there may be uterine contraction, 
it is not of a proper kind. The pain in such cases may be severe enough, 
but it is spasmodic and variable in character, and, instead of beginning 
in the cervix and extending upwards, as in a true labor pain, it com- 
mences usually in the fundus or body, and is attended with no symp- 
toms indicating progress towards delivery. These pains, which are re- 
ferred to the region of the fundus, and not to the loins as in normal 
labor, probably depend upon some irritation, having its origin, in a 
large proportion of cases, in some derangement of the digestive system. 



260 LABOR AND ITS PHENOMENA. [CHAP. 

The leading characteristics, then, of what, for the sake of distinction, 
we call true labor pains, are uterine contractions, which commence at 
the os, and thereby prevent, by the constriction of its sphincter fibres, 
the descent of the umbilical cord, or of such parts of the foetus as might 
impede delivery. These contractions are accompanied with pains, 
which may begin in front and pass round to the sacrum, but which are 
generally referred mainly to the lumbar and sacral regions. 

From an early stage of labor, the tissues are prepared for their new 
function, by a profuse secretion from the vagina and cervix of a thick 
colorless mucus, Avhile the parts from which it Hows become softer and 
more cushiony. This discharge, which is occasionally tinged with 
blood, is frequently mixed with little semi-solid albuminous masses, 
and is very obviously provided by nature for the purpose of lubricating 
the parts, and thus facilitating the progress of the foetus along the canal 
through which it has to pass. Upon the quantity of this secretion, the 
ease of the labor undoubtedly depends in no small degree; not by its 
lubricating action alone, but because its appearance involves a soften- 
ing and general preparedness of the tissues, dependent upon the un- 
loading of the congested vessels. There is no sign upon which, as in- 
dicating the probable duration of a case of labor, the accoucheur looks 
with more confidence than this ; and from a copious secretion and re- 
laxed condition of the parts, he augurs an easy and speedy labor, while 
from a dry, constricted, and rigid vagina, he learns that in all prob- 
ability a lingering exhausting labor will lead to a tardy delivery. 

The phenomenon which essentially attaches to that stage of labor 
which we are now considering, is the dilatation of the os and cervix, 
and it has, on that account, been called by some the "stage of dilata- 
tion." From what has already been said with reference to the nature 
of uterine contraction, it is evident that the effect of each individual 
pain, when efficient, must be to contribute to the opening or dilatation 
of the os. And, further, it must be obvious that, while the membranes 
are intact, the presenting part of the child can play but a trifling part 
in the mechanism of distension. The more attention we give to this 
subject, the more must we admire the admirable adaptation of means 
to an end which nature has in this instance adopted, where the object 
is, as we must remember, not only the expulsion of a solid body through 
a certain channel, the integrity of which must be preserved, but its ex- 
pulsion in such a way as may least endanger its independent vitality. 
It is for that purpose, doubtless, that the membranes are thus preserved. 

The first efficient contraction having probably resulted in an opening 
of the cervix to a trifling extent, and the tissues being sufficiently re- 
laxed to admit of satisfactory progress, we are enabled to trace the pro- 
cess of dilatation through all its subsequent stages. When the os has 
so far yielded, the membranes, which are here separated from their 
uterine attachment, commence to protrude in the form, first of a watch- 
glass, and then of the extremity of a pouch or bag, which has been 
termed the " bag of waters." Following the operation of a very ob- 
vious law already alluded to, this phenomenon implies, primarily, an 
attempt, consequent on the uterine contraction, on the part of the waters, 
to escape in the direction in which resistance is least. The special 



XV.] TERMINATION OF THE FIRST STAGE. 261 

function, however, of this bag is to effect the further dilatation of the os, 
and we can conceive no means which could be more admirably adapted 
to this object than the graduated fluid pressure which is thus brought 
to bear upon the os equally in its whole circumference. It constitutes, 
in fact, in its action during a pain, a hydrodynamic force acting at once 
safely and powerfully upon the whole of the os. But another effect of 
this action is of even higher physiological interest, for in it we observe 
a means by which the head of the child is protected from all pressure 
during the first stage. If we make an examination, in the interval 
between the pains, when the os is moderately dilated, we can generally 
feel quite distinctly, through the membranes, the head, or other pre- 
senting part, and are able to distinguish, for example, the different 
sutures and fontanelles. A pain then comes on ; but, instead of the 
head being driven downwards against the still rigid os, it recedes, and 
the bag of waters takes its place in effecting that dilatation which, when 
premature rupture of the membranes occurs, must of necessity be per- 
formed by the head itself. And the result, when that occurs, is, as 
every one knows, protracted labor and increased risk to the child. As 
the termination of the first stage approaches, the protrusion of the bag 
of the membranes becomes more and more marked ; and as, at the same 
time, the pains 'usually become more violent, it often excites our aston- 
ishment that rupture is so long delayed, and we look for its occurrence 
at every pain. The bag by this time forms in the vagina a tumor of 
considerable size, and, in some cases, where the membranes are un- 
usually resistant, this tumor completely fills the vagina, and even pro- 
trudes externally, a condition which, as we shall have occasion after- 
wards to notice, constitutes a serious impediment to delivery. In such 
cases, the bag of waters, having performed the duty for which it was 
designed, is no longer of any use, and may, under ordinary circum- 
stances, be ruptured without hesitation. 

This purely mechanical force, although we believe it to be the chief, 
is certainly not the only one which is brought to bear in the course of 
the process of dilatation. For we cannot doubt that it is powerfully 
assisted by the contraction of the longitudinal fibres of the uterus, 
which tend to drag the margin of the os upwards at the same time that 
the fluid is being forced downwards, and some have gone so far as to 
believe that it is mainly by their agency that the dilatation of the os 
is effected. Without crediting this latter assumption, we may look 
upon these longitudinal fibres as antagonistic, in their action, to the 
circular fibres which surround the os so as to form a sort of sphincter. 
While we admit such an action as this, we must not overlook the fact, 
which has already been demonstrated, that the arrangement of the uterine 
muscular fibres is extremely irregular. Were the number of longitu- 
dinal fibres which are directed towards the cervix greater, and were 
the arrangement of a circular sphincter more distinct, we might more 
readily accept this as the main dilating power; but knowing what we 
do of the irregularity of these structures, we can only accept of it as a 
subsidiary force. There is yet another method by which, according to 
some, the dilatation of the os may be aided. It is assumed by those 
who hold the view alluded to, that there is, in addition to the forces 



262 LABOR AND ITS PHENOMENA. [CHAP. 

above mentioned, an active dilating power which is resident in the os 
itself — a power which acts, not only by opening the os, but also by 
closing it, as has often been observed in retained placenta, and in 
inversion of the uterus. We confess, however, that we cannot consider 
as satisfactory the evidence which has hitherto been offered in support 
of this theory. In cases in which rupture of the membranes precedes 
dilatation of the os, the mechanism of the act is quite different, as in 
that case the walls of the uterus are brought to bear directly against 
the surface of the foetus, the head being forced, at each pain, against 
the circumference of the os, which, at some risk, and by a slower 
process, is thereby dilated. 

A very frequent occurrence on the termination of the first stage is a 
Rigor. This is a symptom which might very naturally excite alarm 
in the mind of a young practitioner, more especially as it is sometimes 
so violent as to shake the bed on which the patient lies. It is, however, 
attended with no diminution of temperature, nor is it in any way 
affected by the application of warmth to the surface. This rigor is in 
fact a phenomenon purely physiological, and is similar to what is 
observed upon dilatation of the other sphincters of the body, a familiar 
example of which is afforded in the shudder which sometimes passes 
over the body during the act of micturition. 

Another familiar symptom is the slight discharge of blood which at 
this moment frequently occurs, the ordinary discharge being mixed, or 
at least streaked, with blood which proceeds from the rupture of small 
vessels in the os consequent upon its extreme distension. This is what 
midwives call a Show. But the crowning act of the first stage is rup- 
ture of the membranes, which usually occurs at the height of a pain, 
and is accompanied with a sudden gush of liquor amnii, usually pro- 
pelled with considerable force, and with a sound which is often quite 
audible to the attendants. If this gush of waters coincides, as it usually 
does, with complete dilatation of the os, it marks the termination of 
the first stage. Complete dilatation of the os must not be held at this 
stage to imply that obliteration of it which converts the parturient 
canal from the fundus uteri to the ostium vagina? into a continuous 
tube, as shown in the figure which follows, for it is not till the second 
stage has well advanced that such an amount of dilatation is effected. 
Full dilatation at the termination of the first stage mean* merely such 
as will permit of the further progress of the head. 

The pains which accompany the first stage are of a character peculiar 
to themselves, and are of a more teasing, worrying, and wearing nature 
than the more severe agony which subsequently occurs. The chief 
annoyance that the woman feels is from the fact that she fancies she is 
making no progress, and the stage is, therefore, often to her wearisome 
and tedious in the extreme. She questions her attendants again and 
again as to the probable duration of her suffering, but this is a point 
in regard to which we should be specially cautious in risking an opinion. 
Nothing is so likely to mislead us in this respect as the apparent in- 
tensity of the pain. For not only do certain women bear pain better 
than others, but the same degree of uterine contraction may, in indi- 
viduals of different nervous susceptibility, produce a very different 



XV.] 



DURATION OF FIRST STAGE. 



263 



amount of actual suffering. The intensity of the pain, therefore, is not 
always in proportion to the degree of contraction, and still less is it to 
be held as a safe indication of its efficacy. 



Fig. 




Parturient canal completed by the obliteration of the os and cervix. 



The duration of the first stage varies exceedingly, both in primiparse, 
and in those who have had several children. Considerable difficulty 
in determining this point arises also from the impossibility of fixing 
the exact period at which this stage may be supposed to commence. 
Assuming it, however, to date from the first sensible contractions, we 
may assume that, with ordinary pains, and a normal condition of the 
parts, full dilatation may be effected on an average in about six hours, 
the time in primiparse being somewhat longer than in other women ; 
but the stage may nevertheless last for one hour only, or for twenty- 
four, without the occurrence, in either case, of a single symptom to 
cause us the least anxiety. It has been frequently observed by the 
most experienced accoucheurs that, in those instances in which the first 
stage is tedious, the subsequent stages proceed with unusual rapidity. 
Sometimes, cases in which there is unusual rigidity of the neck of the 
womb come to an unexpected and rapid termination in consequence 



264 LABOR AND ITS PHENOMENA. [CHAP. 

either of rapture of tissue or of sudden relaxation of the sphincter 
fibres. 

The Second Stage. — Upon the termination of the first stage, the 
uterus gathers itself for further effort by tonic contraction around the 
body of the child. The pains now undergo a remarkable change. 
Not only do they continue to increase in frequency, duration, and 
severity, but the whole character of the pain is altered. The woman 
has now a consciousness of a solid body which has to be expelled, and 
she therefore brings to bear upon it, half involuntarily, the action of 
all such voluntary muscles as she has at command. The contractions, 
at the same time, although actually more severe, are much more easily 
borne, — and apparently for this reason, that the woman is now con- 
scious that progress is being made. These are well termed " bearing 
down," or expulsive pains, and this stage has therefore been described 
by some writers as the propulsive stage of labor. Considerable resist- 
ance may still be offered by the os uteri, when rigid, to the advance 
of the head, and, if so, an oederaatous swelling, which is limited in its 
circumference by the pressure of the os, forms on the presenting por- 
tion of the scalp, and may attain a considerable development. This 
is called the " caput succedaneum." The anterior lip of the os may 
also become oedematous, in consequence of pressure between the ad- 
vancing head and the pubis ; but, as a rule, it slips up after a time, 
and the canal then becomes, for the first time, a continuous one. But 
it is usually not until the head has escaped from the embrace of the os, 
that the caput succedaneum forms, its size depending upon the degree 
of resistance which is offered by the perineum, and by the other tissues 
surrounding the ostium vaginae. This swelling is always more marked 
in primiparse, and its exact situation on the scalp depends upon the 
extent to which the movement of rotation, to be afterwards described, 
has taken place. We now find that when the head is forced down 
during a pain, the sutures overlap each other considerably, their situa- 
tion being then indicated by a furrowed or wrinkled line on the scalp. 
The whole auxiliary force, formerly alluded to as residing in the ab- 
dominal and other muscles of expiration, now comes into play, and it 
is a wise provision of nature that, however low the head may stand in 
the pelvis, this seldom occurs until the dilatation of the os is complete; 
for we may be pretty sure that, were it otherwise, laceration would be 
of more frequent occurrence. Every means which may in this way 
strengthen the expulsive effort is instinctively adopted. The respira- 
tion is arrested, the limbs are fixed, and the woman presents the ap- 
pearance of one who is undergoing a powerful struggle of muscular 
strength and energy. The sound of the cry which she emits is also 
indicative of violent effort; indeed, so characteristic is this, that it is 
narrated of an old French accoucheur, that when he went to sleep 
while attending an accouchement, he was always roused from his 
slumbers by the altered nature of the patient's voice to a sense of his 
impending duties. The muscles of the floor of the pelvis, and the 
muscular fibres which enter into the composition of the vagina, aid 
still further the propulsive efforts; while the expiratory muscles are 
stimulated to redoubled energy, by a reflex action starting from the 









XV.] THE SECOND STAGE. 265 

sensory nerves of the vagina. There is every reason to believe, more- 
over, that the pressure exercised upon the uterus by the abdominal 
muscles, constantly increasing as the over-distension of their fibres is 
reduced, is a supplementary cause of the propulsive vigor of the uterus, 
which is, by the contraction of the former, more actively stimulated. 
Violent, however, as the propulsive efforts are, they are not attended 
with that danger to the integrity of the parts which might, perhaps, 
have been expected ; for so soon as they reach such a point as would 
seem to endanger the latter, "the short gasp or cry is," as Tyler Smith 
says, " exchanged for a cry which dilates the glottis, and the pain and 
contraction subside. This cry is a motor action, excited by the emo- 
tion of pain, and instantly relieves the uterus of all extra-uterine pres- 
sure. Thus, the glottis may be compared to a safety-valve, which is 
thrown open by emotion whenever the pressure becomes more than can 
be borne with safety." The presenting part, which now approaches 
the outlet of the vagina, soon presses directly upon the perineum, 
which bulges downwards; and, at the height of a pain, when this 
bulging is most marked, that part of the child which is to be first 
born, presents itself at the vulva. This is admirably shown in the 
accompanying engraving. The rectum now becomes flattened, and the 
sphincter dilated, so that any fecal matter which may have been lodg- 
ing there is unavoidably expelled. The margins of the anus being 
dragged apart, the anterior wall of the rectum thus becomes, as it 
were, a temporary portion of the perineum, as is shown in the figure, 
while the perineum itself becomes more and more distended, for which 
modification, indeed, its structure, and the nature of the attachment of 
its muscles admirably adapt it. The hemorrhoidal veins are frequently 
much distended, and the dilatation of the perineum goes on both lon- 
gitudinally and transversely, in a progressive manner, proportionally 
to the violence of each pain, with which the perineum projects as far 
as is safe ; while, on the subsidence of the pain, the elasticity of the 
perineal structures causes the head again to recede. 

Alternately advancing and retiring in this way, but always gaining 
ground, the head ultimately passes the distended aperture in a direction 
forwards, under the pubic arch, the perineum now presenting the ap- 
pearance of a thickened membrane. In many cases the head is arrested 
by the cessation of a pain, just at the moment when its greatest diam- 
eter is encircled by the circumference of the vulva, but it does not now 
recede. This has been called the stage of "crowning," and may be 
looked upon as favorable to the integrity of the soft tissues. A final 
pain now brings the presenting part into the world, and this period, 
which immediately precedes delivery, is that at which the suffering of 
the woman reaches its highest pitch, — sometimes amounting to frenzy, — 
and it is wisely and mercifully provided, in some codes of jurisprudence, 
that any act of violence committed at this moment is viewed with 
special leniency. Upon the birth of the head, the woman enjoys a 
brief interval of relief, but the pains soon return, and complete the 
delivery of the remainder of the child. The external parts, which 
have become contracted around the neck upon the passage of the head, 
are again dilated, and the shoulders are expelled. It will be found, 



266 



LABOR AND ITS PHENOMENA. 



[CHAP. 



however, that it is not invariably the anterior shoulder, as is stated in 
many works, which is first expelled ; for, in a very considerable number 
of instances, that shoulder which lies towards the perineum takes 
precedence in its passage into the world. During this stage, a slight 
amount of laceration generally takes place, in the direction of the dis- 
tended perineum, and in primiparae, indeed, the fourchette seldom, if 



Fig 




Distension of the perineum. (After Hunter.) 






ever, escapes. The remainder of the infant then passes, and with it a 
gush of blood and the rest of the amnionic fluid. The uterus now 
contracts firmly on the placenta, and may be felt, as a hard globe, 
above the symphysis ; while the abdominal walls become flaccid, and 
the mother experiences a feeling of calm and perfect rest, which yield 
to her, from the comparison, a sensation of delicious repose. 

The Third Stage. — The final contractions of the second stage are 
sometimes so violent as to expel the Placenta along with the child. 
This, however, is an unusual occurrence, and what generally takes 
place, when the case is absolutely left to nature, is as follows : The 
child, on its birth, remains connected with the placenta by means of 
the cord, which, for a time continues to pulsate. The latter being 
divided, in the manner to be described in the following chapter, the 
woman remains at perfect rest for an interval of about ten minutes or 
a quarter of an hour, on the average. The uterus then begins sponta- 
neously to contract upon the placenta, the expulsion of which organ 
constitutes the Third Stage of labor. The pains of this stage, although 
of the same expulsive nature as those which preceded it, are compara- 
tively trifling, and are accompanied with more or less of the blood 
which has escaped from the ruptured utero-placental vessels. They 
were, on this account designated by the older writers dolores cruenti. 
A few of these contractions is generally sufficient to effect the complete 
separation of the placenta and its propulsion into the vagina, but the 
feeble contractile power of the latter often renders it necessary to give 



XV.] 



THE THIRD STAGE. 



267 



some assistance in the delivery. The placenta and the adhering mem- 
branes being expelled, this final act terminates the labor. 

The description originally given by Baudelocque as to the mechan- 
ism of the birth of the placenta, has been adopted by almost all modern 
authors, and the demonstration which has lately been given of it by 
Schultze in his admirable Wandtafeln (see Fig. 99), is in every respect 
confirmatory of the views of the great French obstetrician. The descrip- 
tion given by them of the process is, that the placenta passes through 
the vagina inverted, with its foetal or amnionic surface turned outwards, 



Fig. 99. 



Fig. 100. 





Alleged inversion of placenta in the 
third stage. 



Normal position of the placenta in 
the third stage. 



an assertion which, in so far as the natural process is concerned, is 
quite incorrect, That the placenta passes, in a large number of cases, 
in the manner shown in the accompanying figure, is probably true 
enough, but the reason is, that the practice of pulling on the cord is 
resorted to with too great frequency in general practice. For if we 
believe that the normal process is thus represented, it will seem rational 
enough, when delay occurs, to pull gently towards the ostium vaginse 
that portion which nature intends should first be born. In cases, how- 
ever, which are left entirely to nature, it will almost invariably be 
found that it is not the foetal surface but the edge of the placenta which 
presents, and it is this part, overlapped it may be by the membranes, 
which will be found to pass first both into the vagina and through the 
vulva. This is the description which has been given by Lemser, 
Cazeaux, and some others, and, more recently, Dr. Matthews Duncan 
has, in a paper distinguished by his usual ability, put the matter in a 
perfectly clear light. In his drawing, which we here reproduce slightly 



268 MANAGEMENT OF NATURAL LABOR. [CHAP. 

modified, the placenta is shown folded upon itself, with the detached 
uterine surface turned towards the observer, " but the folds are," as he 
observes, "according to the length of the passage, not transverse to it, 
as inversion or presentation of the foetal surface imply." We are fully 
persuaded that the observation of half a dozen cases, in which no inter- 
ference with the cord is permitted, will convince any one of the truth 
of these assertions. It will be shown presently that they involve some 
points of practical importance. 

The uterus may now be felt behind the pubes firmly contracted, and 
on the maintenance of this tonic contraction depends mainly the safety 
of the woman from the dangers of post-partum haemorrhage It some- 
times occurs, however, that the rhythmical efforts persist, when the 
womb may be felt in alternate stages of relaxation and contraction 
without necessarily any particular loss of blood. 



CHAPTEE XVI. 

MANAGEMENT OF NATURAL LABOR. 

DUTIES OF THE ACCOUCHEUR — PRELIMINARY ARRANGEMENTS — FALSE PAINS AND 
THEIR TREATMENT — ARMAMENTARIUM OF THE ACCOUCHEUR — POSITION OF THE 
WOMAN DURING LABOR — DIGITAL EXAMINATION : POINTS TO BE EXAMINED — 
THE PATIENT NOT TO TAKE TO BED DURING THE FIRST STAGE — PREPARATION 
OF THE BED, ETC. — ABDOMINAL MUSCLES TO BE CALLED INTO PLAY DURING THE 
SECOND STAGE — MANAGEMENT OF THE ANTERIOR LIP OF THE OS — OBSTACLES 
ARISING FROM RIGID OS ; AND FROM NON-RUPTURE OF MEMBRANES — USE OF 
STETHOSCOPE— VIEWS REGARDING SUPPORT OF PERINEUM — TREATMENT IF 
LACERATION IS THREATENED — CAUSES OF LACERATION — BIRTH OF THE HEAD 
— PASSAGE OF THE TRUNK — TREATMENT OF SUSPENDED ANIMATION IN THE 
CniLD — LIGATURE OF THE CORD — MANAGEMENT OF THE THIRD STAGE : CREDe'S 
METHOD — APPLICATION OF ABDOMINAL BANDAGE — TREATMENT OF THE WOMAN 
AFTER DELIVERY. 

Having in the last chapter fully considered the various phenomena 
attendant upon natural labor, the subject of the duties of the accou- 
cheur remains for our consideration. It is fortunate that, in a very 
large proportion of all cases, the various stages of labor are effected 
by the unaided efforts of nature, in a manner which renders any 
"assistance" on the part of the accoucheur, in the ordinary acceptation 
of the term, quite unnecessary. Indeed, the duties which he has to 
discharge might, in nineteen cases out of twenty, be performed as effi- 
ciently and perhaps more agreeably to the feelings of the patient by a 
thoroughly trained and intelligent nurse. But, in the twentieth case, 
something may occur, — and it may be, quite unexpectedly — which sud- 
denly demands special experience, operative skill, and a thorough 
practical knowledge of the healing art. It is only, however, as has 



XVI.] PRELIMINARY ARRANGEMENTS. 269 

already been observed in the introductory chapter, by a careful study 
of the normal process, that it is possible for us to recognize speedily and 
with precision deviations from the physiological standard; and this 
reason alone would suffice as an apology for a branch of practice which 
some look upon with disdain. But a more important reason still is to 
be found in the fact that many of the dangers and complications of 
labor arise so suddenly that, unless aid is at hand, the life of mother 
or child, or of both, may be sacrificed ; for, as at present trained, it is 
rare to find a nurse who has the skill requisite for the management 
even of the more remediable complications of midwifery. 

There are numerous points of detail which contribute greatly to the 
comfort of the patient, in regard to which an intelligent nurse is usu- 
ally well informed, and the management of which may be left in her 
hands, if we have confidence in her ability. This, however, manifestly 
applies only to the wealthier classes, who alone can command the 
services of such skilled attendants; but, as the practice of the great 
majority of professional men extends, more or less, in directions where 
he has himself to discharge many of the duties which are more properly 
those of the nurse, it is necessary that every young practitioner should 
thoroughly understand what these are. And, in any case, the failure 
of the nurse may devolve these duties upon him, so that it is of further 
importance that he should be familiar with them, in order that he may 
be able at once to detect incompetency, and to remedy its defects. 

The judicious management of a case of labor may be held to include 
certain preliminaries, in regard to which women, and more especially 
primiparse, often require some advice. The systematic neglect of the 
bowels which women so often practice, is likely, if persisted in, to be a 
cause of much discomfort. A pregnant woman should therefore be en- 
joined on no account, as the period of labor approaches, to neglect this 
function. In most cases it is proper, by a laxative given at the outset 
of labor, or by the administration of an enema, to make sure that the 
lower bowel is empty; for, if this be neglected, the labor will be much 
more disagreable to the accoucheur, and may also be unduly protracted. 
If her health be tolerable, she must not be encouraged to consider her- 
self an invalid, but should be recommended to take such moderate 
exercise as may seem appropriate, while the tone and general vigor of 
the system is maintained by a sufficient diet, which may be generous, 
but not stimulating. During the last weeks of pregnancy, the descent 
of the womb often renders a woman more capable of moving about, 
from which " it would almost seem," as Rigby says, " that nature 
intended she should use exercise at this period, and thus prepare her, 
by increased health and strength, for a process which requires so much 
suffering and exertion." 

The perverted and irregular contractions, to which we have already 
alluded under the name of " false pains," may cause the summoning of 
the accoucheur long before his services as such are required. Those 
pains will often, upon strict investigation, be found to depend upon 
derangement of the bowels, or upon reflex irritation starting from some 
other source ; and, in this, as in many other cases, the success of the 
treatment will depend upon the intelligent appreciation of the cause. 



270 MANAGEMENT OF NATURAL LABOR. [CHAP. 

The uterus* may be the seat, as every one knows, of congestion, as well 
as of neuralgic or rheumatic affections, the latter being of much less 
frequent occurrence than was at one time supposed; and each of these 
conditions may involve special or peculiar treatment. But, in most 
cases, the treatment will consist in rectifying the state of the bowels, 
and, thereafter, in allaying uterine irritation by the administration of 
an opiate, which will generally at once arrest the spasms, and will also 
procure refreshing sleep for the patient, of which she may for some 
time have been bereft. Should any reliable evidence of congestion 
exist, it may be advisable, when the period of natural labor is close 
at hand, to reduce this by external fomentations, and by tartar emetic 
combined with small doses of opium. For, in some such cases, it will 
be found that an unusual rigidity or dryness of the parts exists, which, 
if unaltered, will almost certainly act as an impediment to labor. By 
mistaking false for real pains, we may, in our ignorance, allow the 
woman to go on suffering that which we generally have it in our power 
to alleviate. 

The practitioner will often, to his great annoyance, be called to the 
bedside of his patient, when, although labor may have commenced, the 
period is yet distant at which his services will be required. Such a 
summons should, however, be promptly obeyed. For, although in 
most cases it will be time lost, it is of the greatest possible importance 
that anything abnormal should be detected as early as may be in the 
course of labor. We are then in a position leisurely to determine our 
plan of procedure; and, should any operative assistance be required, 
to select that period for it which is most favorable in the interests of 
mother and child. We are able, moreover, when we have an early 
opportunity of examining the case, to form an opinion, to which expe- 
rience will lend confidence, as to the probable duration of the case, and 
this enables us to leave the patient for a time, and to attend to such 
other of our professional duties as may be most urgent. If the symp- 
toms are such as to convince us that the woman is really in labor, we 
should always make an examination before leaving. In proposing this, 
especially in women who are in labor for the first time, we should 
never forget the consideration which is due to the feelings of the patient, 
whatever be her rank in life. For it cannot be otherwise, than that a 
woman must look upon such an examination as is necessary, by a person 
of the other sex, with apprehension, if not with abhorrence; but if the 
necessity be first explained to her in a few kindly words, she will rarely 
fail to appreciate the good feeling which prompts them, and will submit 
without a murmur to whatever may be deemed essential to her safety 
or comfort. A similar feeling should guide us in everything we do in 
the practice of midwifery, and if so, we shall seldom fail to win the con- 
fidence of our patient. To lay down, however, as some have attempted 
to do, rules for the guidance of the young practitioner in this respect, is 
simply absurd ; for, to tell a man of grave demeanor to look cheerful, 
and a man of lively and jocund spirit to look grave, is to make both 
artificial, and more like fools than rational beings — a state of matters 
little likely to establish confidence or to engender esteem. 

There are certain articles of his armamentarium which the accoucheur 






XVI.] POSITION OF THE WOMAN. 271 

should look upon as indispensable, and should therefore carry with him 
as a matter of coarse : these are an elastic catheter, a small vial of some 
approved preparation of opium, and a similar quantity of the liquid 
extract of ergot. To these may be added chloroform and sal volatile ; 
and, if we are going to any distance, we should certainly take the for- 
ceps, which does not occupy much room in the gig or saddle-bag, 
whereas its absence may possibly cause many hours of delay, and in- 
creased clanger. It is the duty of the nurse to provide narrow tape or 
strong thread for tying the cord, and to have in readiness the abdominal 
bandage, scissors, hot and cold water, and a supply of napkins; but, 
as it will often fall to the lot of the medical attendant to see to these 
preparations himself, he should, at least, be provided with such material 
as may be depended upon for ligaturing the cord ; and we take it for 
granted that he habitually carries with him scissors and a stethoscope. 
For obstetric use, a stethoscope with an elastic stem is to be preferred. 
He should also give a general glance around, and see that everything 
is ready which may be necessary for the comfort or safety of the patient. 
In making an examination, the most convenient position for the 
accoucheur, as well as the patient, is that which is invariably adopted 
in this country. The woman lies on her left side, with her back to 
the examiner, and near the edge of the bed, which must, if necessary, 
be previously so arranged as to admit of this. 1 The index and middle 
finger of either hand — the right being usually preferred, although the 
left has certain advantages — being then smeared with lard or oil, are 
passed over the perineum, and gently into the vagina up to the os uteri. 
It is usual to select a period of a pain for the examination ; but, if so, 

1 " In the earliest periods of history, women appear to have been delivered in a 
sitting posture, as is described in the first chapter of Exodus. This mode was re- 
vived in comparatively modern times ; thus Ambrose Fare, in 1573, speaks of a 
labor-chair, with an inclined back, which he preferred to a common bed. Labor- 
chairs were brought into very general use upon the Continent in the beginning of 
the last century by Deventer, and, although they have been in a great measure 
discontinued in modern times, there are still some districts in Germany where they 
continue to be used. It is a species of chaise percee, furnished with straps, cushions, 
etc., by which the patient can fix her extremities, and thus enable the abdominal 
muscles to act with the greatest power. In some remote parts of Ireland and also 
of Germany, the patient sits upon the knees of another person, and this office of 
substitute for a labor chair is usually performed by her husband. Labor-chairs, as 
far as we are acquainted with their history, were never used in this country, nor 
have they been used for the last century in France, where the patients are usually 
delivered in the supine posture, on a small bed upon the floor, which has not inaptly 
been termed lit de misere. A modification of the labor-chair is the labor-cushion, 
first used by Unger, and afterwards by the late Professor von Siebold of Berlin, and 
Professor Cams of Dresden ; it is a species of mattress, with a hollow beneath the 
nates of the patient for receiving the discharges which take place during the labor. 
The patient is compelled to lie upon her back during the greater part of labor, and 
thus maintain the same position for some time, which must necessarily become irk- 
some, and even painful to her. In this country and in Germany the patient is 
delivered upon a common bed, prepared for the purpose as above mentioned; in 
England she is placed upon her left side, the nates projecting to the edge of the bed, 
for the greater convenience of the accoucheur ; in Germany — except in Vienna and 
Heidelberg, where the English midwifery has in a great measure been introduced 
by Boer and Naegele — the patient is delivered upon her back. In former times, 
the supine posture was also used in this country, but for about a century the 
position on the leftside has been preferred." — A System of Midwifery, by Edward 
Eigby, M.D. 



272 



MANAGEMENT OF NATURAL LABOR. 



[CHAP. 



the finger must not be withdrawn until we have examined the parts in 
the state of repose also, for the protrusion of the bag of waters during 
a pain makes it difficult to ascertain the presentation, without risking 
premature rupture of the membranes by undue violence. The points 
which one ascertains in the course of the examination are, in the first 
place, the state of the vagina, whether it is soft, relaxed, and well 
lubricated with mucus. In regard to the os uteri, we observe if it is 
soft and dilatable, or rigid and unyielding, and to what extent it has 
become dilated, if at all. Information is, further, obtained, as to 
whether the membranes are ruptured ; whether we have to deal with 
a natural presentation ; and if there is any pelvic deformity or morbid 
growth which might impede the progress of labor. And, finally, we 
may thus recognize at an early stage prolapse of the cord — a condition 
which calls for constant care and anxiety, so long as the labor may 
last. With this view, also, it is usual to make an examination at the 
time of the rupture of the membranes, as it is at this moment that the 
loop of the cord frequently descends ; and, besides, an examination 
now enables us, more surely than before, to determine the position of 
the presenting part. The mode of examination above described is 



Fig. 101. 




Mode of digital examination 



represented in the accompanying figure, in which the examination is 
being conducted with the right hand. In most cases one finger, as 
here shown, will suffice, and this should always be attempted when the 
examination seems to cause unusual pain. The student and young 
practitioner should avoid making too frequent examinations, for, not 
only does this irritate the parts, but it tends to remove, at each succes- 
sive examination, a portion of the lubricating medium, upon the quan- 



XVI.] PREPARATION OF THE BED. 273 

tity of which depends, in some measure, the satisfactory issue of the 
case. The practice of previously smearing the finger with some bland 
lubricant is resorted to on every occasion in which an examination is 
found to be necessary, not so much to facilitate introduction — which 
the abundance of mucus generally renders easy enough — as to supply 
the place of any mucus which may be removed, and in a certain class 
of cases to protect the finger. The operator should never omit, after 
an examination, to address a word or two to the patient in a cheerful 
tone; and, if the presentation be natural, and you are then able to 
say so, she will always be gratified by hearing that "all is as it 
should be." 

So long as the os uteri is not fully dilated, or, in other words, so 
long as the first stage continues, the patient should be encouraged to 
believe that this is a stage which is merely preliminary to the act of 
parturition ; and that, therefore, she should not lie in bed, but rather 
walk about in the intervals between the pains, and take such light food 
as she would under ordinary circumstances. If she can be induced to 
occupy her attention, as far as possible, by any familiar occupation, 
however trivial, it will be to her advantage, by relieving the tedium of 
her suffering. If this cannot be done, her attendants should try, by 
cheerful conversation, to beguile the time, and to divert her mind from 
the gloomy apprehensions which are of frequent occurrence at this 
period. The accoucheur should not remain in the room during this 
stage unless there be any special necessity for it, although he may visit 
it occasionally. To do otherwise would encourage her to expect assist- 
ance at his hands, which it is not in his power to afford ; and, more- 
over, his presence would to her seem to imply that he expected a speedy 
termination of her sufferings. During this period, the woman is fre- 
quently advised by ignorant attendants to press down, and with this 
view footstools are placed at the foot of the bed, and towels are tied to 
the bed-post, by means of which she may fix the trunk, and bring the 
whole force of the expiratory muscles to bear. This acts most inju- 
riously on the progress of the labor, for the stage is one of dilatation, 
and not of propulsion ; and, if the muscles referred to are thus brought 
prematurely into play, the voluntary expulsive force is fruitlessly ex- 
pended before the stage arrives at which it may properly be employed. 
Nothing, in fact, is more certain, than that any attempt, either on the 
part of the woman, or, on the part of the practitioner, by forcible dila- 
tation of the os, the administration of ergot, or the exhibition of stimu- 
lants, to hurry delivery, must be strictly avoided in the course of the 
first stage of a natural labor. And, even in cases where its duration 
is prolonged far beyond the average, this of itself is no excuse for in- 
terference, unless the general symptoms indicate that it is our duty to 
accelerate the labor by such means as are within our reach — a state of 
matters which is of rare occurrence. When the pains flag, it has often 
been found that the administration of an enema for the purpose of 
emptying the lower bowel, acts further as an efficient stimulant to 
uterine contraction. 

The pains usually become more severe as the termination of the first 
stage approaches, and at this period it is advisable that the woman 

18 



274 MANAGEMENT OF NATURAL LABOR. [CHAP. 

should go to bed, more especially if she has previously borne children, 
as there is a risk of the sudden propulsion of the child immediately 
upon the rupture of the membranes. Previous to this, the nurse pre- 
pares the bed — which should not be too soft — by placing over it a 
piece of india-rubber sheeting to protect it from the discharges. Upon 
this a folded sheet, about two and a half to three feet in width, is 
placed across that part of the bed upon which the pelvis of the woman 
lies. By this simple arrangement, the sheet may be gradually pulled 
through as it becomes soiled with successive discharges of liquor amnii, 
or of blood, and at the end of the labor it is completely removed along 
with the final discharges which accompany the birth of the placenta. 
The ordinary night-dress which the patient wears, or rather that part 
of it which is beneath her as she lies, should be rolled up above the 
waist, and the lower part of the body covered with a petticoat which 
opens all the way down, and she should then be covered with such 
bedclothes as the season of the vear and her own feelings mav render 
necessary. She lies on her left side, as has already been stated, with 
her back to the practitioner, and her head consequently to his left hand ; 
and one of the advantages of such a position is that she is not disturbed 
by seeing such preparations as may be necessary for her assistance or 
relief. It is by no means essential that she should occupy this posi- 
tion continuously till the termination of labor. To do so would be 
irksome in the extreme; so that she may be permitted to lie at will on 
either side, or on the back, reverting necessarily to the left side when 
any occasion may arise for renewed examination. 

For reasons above stated, frequent examinations are always to be 
avoided. From time to time, however, examinations may be instituted 
with the view of ascertaining the rate of progress which is being made. 
This has the further advantage of allowing the busy practitioner to ab- 
sent himself from time to time, for such a period as he judges to be 
quite safe; but, in this respect, he must always be cautious, as he will 
be blamed if absent at the critical moment. In some cases, even in 
prim i pane, a sudden and violent increase in the expulsive force un- 
expectedly occurs, when, if the parts be soft and dilatable, the birth 
may take place with extraordinary rapidity. All calculations as to the 
probable period of delivery are very uncertain, and although experi- 
ence gives a certain confidence to the opinion which may be formed, 
we cannot be too cautious in expressing it; for, not only may it end 
abruptly as we have seen, but, in other cases, labors, which up to a 
certain point have advanced in a manner which seemed to render 
speedy delivery almost a certainty, are suddenly suspended by failure 
of uterine action, or by some other cause. The child may, under such 
circumstances, actually be arrested on the very threshold of its en- 
trance into the world. 

So soon as rupture of the membranes has taken place, the sheet be- 
neath the patient should be pulled by the nurse towards the edge of 
the bed, so that she may rest on a dry portion, and avoid the discom- 
fort of lying on a wet bed. The stage of propulsion now usually com- 
mences, and it is quite proper, in many cases, to encourage the woman 
to avail herself of the aid of the abdominal muscles. In most cases, 



XVI.] PROGRESS OF THE SECOND STAGE. 275 

she will do this instinctively, and requires no instruction wiiatever ; but, 
in others, there is a disposition to waste the force of the expiratory 
muscles in cries, which are worse than useless, and it is in these cases 
that encouragement should be given. In regard to the means already 
referred to for fixing the trunk, the accoucheur will use his own discre- 
tion as to how far they are to be permitted ; for, if the pains are of 
more than usual violence, we must rather restrain than encourage her 
efforts, while if, on the contrary, they are slow and inefficient, we may, 
with perfect propriety, allow of any means which may act by increasing 
the deficient propulsive force. At any time in the course of the labor, 
but more especially, perhaps, about the commencement of the propulsive 
stage, difficulty may arise from retention of urine, in consequence of 
mechanical closure of the urethra. This requires the use of the cathe- 
ter, which is to be employed with caution and with due reference, as 
has already been mentioned, to the anatomical modifications which 
attend pregnancy. The pressure consequent upon the descent of the 
head, often gives rise to cramps in the thighs, a symptom which some- 
times aggravates very greatly the suffering of the patient. We shall 
not stop here to consider whether this is due to direct pressure upon 
the large nervous trunks, or to a reflex action ; but, in regard to the 
treatment of what is a troublesome complication, although not a dan- 
gerous one, it can only be said that if emptying the bowels by an 
enema, and warm friction of the thighs should fail to remove the spasm, 
we can but try such other means of palliation as may occur to us, for 
in all probability the patient will not enjoy complete relief, until the 
termination of the labor has removed the cause which is responsible 
for the symptom in question. 

As the head descends in the pelvis, after the termination of the first 
stage, it not unfrequently happens that the anterior lip of the os re- 
mains in an oedematous condition, indicative of pressure of the anterior 
uterine wall between the presenting part and the symphysis pubis. 
This constitutes a very manifest impediment to the progress of the 
labor. It has been said by some of the best authorities that under such 
circumstances we should never interfere. "All attempts," says Rigby, 
" to push it above the head are objectionable, because, in the first place, 
the finger cannot reach sufficiently high to effect the object, and, there- 
fore, the swelling descends again to its former situation ; and, secondly, 
the efforts to push it up only tend to inflame it, and increasing the 
swelling." To this we must demur. Any attempt, rudely or forcibly, 
to push up the anterior lip, even when it exists as a manifest impedi- 
ment, should certainly be avoided; but we are bound to add that, in 
many cases, it may be pushed beyond the head with perfect safety, and 
in this way the impediment to delivery may be at once obviated. The 
swollen part should, during the interval between two pains, be gradually 
and cautiously pressed up as far as possible beyond the head. If the 
finger be removed, the tumor descends at once, as Rigby says ; but if 
it be kept in position until the next pain comes on, the head will often 
pass down, and the cervix be retracted upon it, precisely as occurs at 
the moment of the passage of the head through the ostium vagina?, by 
the action of the levatores ani muscles. This cannot be effected in 



276 MANAGEMENT OF NATURAL LABOR. [CHAP. 

every instance, bat the attempt, if cautiously performed, is free from 
risk, and in a very considerable proportion of cases, is attended with 
complete success. 

The further progress of the labor brings the head, or other present- 
ing part of the child, downwards, towards the floor of the pelvic cavity. 
In a certain number of cases, it is, however, impeded in its progress by 
mechanical hindrances, which it is in our power to remove. The mem- 
branes, for example, may be so tough as to have resisted an ordinary 
amount of force at the period at which they are usually ruptured ; or 
they may be distended by a very unusual quantity of liquor amnii; in 
either of which cases the bag of waters may constitute an impediment 
to delivery, which can only be removed by artificial rupture, so as to 
permit the descent of the head. In other instances, the os uteri pre- 
sents a condition of abnormal rigidity, its margin being, at the acme of 
a pain, hard, rigid, and tender. In former times, the practice univer- 
sally adopted in such a case was bloodletting, and we do not for a mo- 
ment doubt that the effect of the operation was to relax the rigidity, 
and permit the descent of the head; but the cases in which we would 
be justified in bleeding during labor are very limited. It is safer to 
give tartar emetic in nauseating doses, which will be found to have an 
equally beneficial effect, and one, at the same time, from which the sys- 
tem can be more easily released than when, by misadventure, too much 
blood has been abstracted. We have, however, in chloroform a far pref- 
erable agent, which, in such cases, exercises a most powerful influence 
upon the rigidity of the os. This we should never fail to avail our- 
selves of in cases requiring operative interference. Chloroform, indeed, 
in such instances, fulfils a threefold indication, by subduing the rigidity 
we are speaking of, arresting voluntary movements, and allaying reflex 
susceptibility. Of late, chloral hydrate has been extensively used for 
the same purpose and with satisfactory results; and in France, bella- 
donna has enjoyed a high reputation, which, however, is somewhat 
doubtful. 

The stethoscope should be employed from time to time during the 
course of a tedious labor, to ascertain the vitality and vigor of the foetus, 
for there are cases in which the life of the foetus may be compromised, 
while that of the mother undergoes no risk whatever. Some, indeed, 
have recommended that, in labor apparently the most uncomplicated, 
the stethoscope should be frequently used, so that risk to the life of the 
child may thus be reduced within the narrowest possible limits. 

When the further progress of the case has brought the head to press 
against the perineum, as is shown in Fig. 98, it distends or bulges that 
structure outwards, or rather downwards, more and more during every 
succeeding pain; and the position of the patient on the left side enables 
us often to watch the process without her being aware of any exposure. 
The axis of motion is now no longer downwards, but forwards in the 
direction of the subpubic angle, as will be fully described in a subse- 
quent chapter. A very usual practice at this stage, is to separate the 
knees by means of a pillow or otherwise, so as to encourage, as far as 
possible, the movement in this direction. This has, however, been 
condemned by some of the best authorities, on the ground that labor 



XVI.] SUPPORT OF THE PERINEUM. 277 

should be habitually retarded at this stage, an argument, the force of 
which, we confess, we can scarcely admit. And this for two reasons : 
first, because the position on the side, which involves apposition of the 
knees, is singularly unfavorable to movement of the head in the direc- 
tion which we have indicated as normal ; and, second, because, in a large 
majority of cases, the separation gives the woman great relief, a fact 
which is familiar to every experienced nurse. 

The most important point, however, connected with this stage of the 
process is, undoubtedly, the Support of the Perineum, — a mode of pro- 
cedure which is recommended in some form or other by most writers 
on obstetrics. Many years ago, our attention w T as, by an accidental cir- 
cumstance, very particularly directed to this matter, and we published 
some time afterwards a paper on the subject, 1 which w r as founded not 
only on a careful clinical study of the phenomena of this stage of labor 
when unaided, but also on a critical examination of the views entertained 
by those who practice support of the perineum, and of the reasons which 
swayed them. The points brought out were mainly these : 

The earlier writers recommended only, in reference to this stage, the 
free use of lubricants and emollients. About the middle of the last 
century, Smellie advocated artificial dilatation of the external orifice of 
the vagina ; Puzos, stretching of the parts along with lubrication ; and 
Roederer, pressing of the perineum towards the sacrum : all these modes 
of treatment differing greatly from the modern procedure. To whom 
the practice of perineal support is originally due is a matter of doubt, 
but, in the treatise published by Professor Hamilton of Edinburgh, in 
1781, we find it mentioned as a distinct system, applicable alike to 
natural labor and to that which is in any way abnormal. This author, 
like Puzos, advocates the use of lubricants, and recommends us to 
release the perineum when the head is being born, " by cautiously 
sliding it back over the face and chin of the child. 7 ' From this time 
writers have, in the main, agreed that, by a support of the perineum, 
lacerations are to be prevented ; but they have not agreed as to what 
" support" is, or to what extent it is to be practiced. It would carry us 
far beyond the limits within which the subject must here be confined to 
examine critically the views which are, or have been, entertained by 
the most approved authorities on this point. We shall, on this account, 
refer only, and that very briefly, to the opinions which are promulgated 
by some of the authorities referred to. 

Dr. Pamsbotham says, "As soon as the head has come to press on 
the external parts, it becomes our duty to take our seat by the bedside, 
and never to move from our position till the child has passed. This 
we do to protect the perineum and to prevent laceration." . . . "Place 
your elbow/' he continues, "against the bedstead, regarding it as a 
fixed point, and allow the perineum to be forced against your hand." 
Fortunately there are few, if any teachers of midwifery who go to 
such an extreme in the recommendation which they give to their 
students ; for we believe that support of this kind can scarcely fail 
sometimes to bring about the very accident which we are striving to 

1 Glasgow Medical Journal. January, 1860. 



278 MANAGEMENT OF NATURAL LABOR. [CHAP. 

avert. Dr. Tyler Smith pointed out many years ago, that pressure 
upon the perineum is apt to excite the uterus to increased contraction 
by a reflex action starting from the nerves which are distributed through 
the former structure, and, on this ground he dissuades us from prac- 
ticing systematic support. Churchill recommends very gentle and 
careful support, and, in concluding his observations on this point, 
informs us that it has been his lot to " witness more than one case 
where rupture was owing to excessive and injudicious support." Den- 
nian only sanctions support in first cases, while Naegele plainly says, 
"under ordinary circumstances, any support of the perineum is un- 
necessary." 

It was a careful study of these opinions among others, along with a 
thorough observation of the process in nature, which led us long ago to 
condemn support of the perineum as irrational and useless in all cases, 
and undoubtedly hurtful in some. It must be admitted, however, that 
the method usually adopted, which consists in very gentle support, 
with the view, mainly, of directing the head forwards, probably does 
no harm ; the palm of the left hand, protected by a napkin, being laid 
along the perineum, and pressed against it during a pain. Two points 
must here, however, be borne in mind ; that the perineum must sooner 
or later yield, and that support necessarily implies opposition to the 
progress of the head. If, therefore, we admit support as a rule of prac- 
tice we shall find ourselves opposing a natural process, and presuming 
to teach nature a lesson. If any one will but take the trouble in a 
single case to watch the admirable manner in which nature effects her 
purpose in dilating the perineum, each pain increasing the dilatation 
by a carefully graduated force, until at last the orifice permits the pas- 
sage of the head, the observation will go further to convince the most 
earnest advocate of the doctrine of support than any mere argument 
can do. And be it remembered always, that, do what we may, rupture 
of the perineum will, in a certain proportion of cases, as is admitted 
by every one, occur. 

The practice of perineal support, then, is, if very gentle, harmless. 
Indeed, we are inclined to admit that, in some cases of deficient con- 
tractile power, it may be beneficial, but in a way very different from 
what the operator counts upon — by exciting more energetic propulsive 
action. The practitioner, however, who never puts his hand to the 
perineum will, we firmly believe, have fewer cases of ruptured perineum 
in his practice than he who admits support in any form as applicable 
to every case of labor ; while, if he adopts the advice of Ramsbotham, 
as above quoted, he will, beyond all reasonable doubt, sometimes cause 
the very accident which he is attempting to prevent. We do not 
think, in reference to this subject, that we take an exaggerated view of 
the case in looking upon it as a relic of " meddlesome midwifery," in 
which we presume by irrational and bungling interference to dictate 
to nature. 

The proper management of this stage — which will be found to be 
attended with results of the most satisfactory kind — consists in watching 
the amount of pressure to which the perineum is being subjected. 
This may be done effectively and easily by keeping a finger on the 



XVI.] LACERATION OF THE PERINEUM. 279 

anterior margin of the perineum, which enables us, with a little practice, 
to gauge with tolerable accuracy the degree of propulsive force which 
is being exercised. Should this exceed the normal standard, so as to 
imperil the integrity of the tissues, we must then order all aids to ex- 
pulsive effort to be removed from the reach of the patient, and at the 
same time encourage her to cry out lustily during the height of a pain, 
or, in other words, to make free use of the safety-valve of the glottis. 
Should circumstances render it expedient to oppose the advance of the 
head with the view of rendering the process of dilatation more gradual, 
this should be done, not by pressure on the perineum, but by pressure 
exercised directly upon the head of the child, which is to be pressed 
towards the hollow of the sacrum. But the effect even of such pres- 
sure is in most cases doubtful, and the greatest possible care must be 
exercised lest we divert the force which should be expended in the 
direction of the pubic arch, and, by bringing it to bear directly upon 
the perineum, thus enhance its risk of rupture. 

In all first cases, the fourchette is slightly lacerated, but the rupture 
seldom extends further. In cases in which there exists morbid rigidity, 
cicatrices, or a diseased state of the parts, the rent may extend deeply 
into the perineum, and even in extreme cases through the sphincter 
into the anus. We must guard, however, against taking too serious a 
view of such a laceration ; for what may seem at the moment of deliv- 
ery to be a serious surgical lesion, turns out in the course of forty-eight 
hours, and in consequence of the retraction of the parts, to be but a 
trifling fissure. It is not, as a rule, by the passage of the head that 
the most serious lacerations are effected ; they are often commenced by 
this, but it is the passage of the shoulders which extends the rupture. 
Sometimes, the perineum gives way under an amount of pressure which 
is comparatively trifling, suddenly yielding in its whole extent like a 
piece of wet parchment; and it is in regard to these cases that a sus- 
picion has arisen as to the possibility of disease in the structure of the 
parts. There is also an increased risk of perineal rupture in certain 
forms of pelvic deformity — such as diminution in the trausverse diam- 
eter of the outlet. This involves an approximation of the tuberosities 
of the ischia, and an abnormal acuteness of the subpubic angle — con- 
ditions which obviously must make the head pass further doivnwards 
in the direction of the perineum, before it is possible for it to move 
forivards under the arch. The unskilful use of instruments is also a 
fertile cause of perineal rupture, and the same may be said of careless- 
ness in operative manipulation. Certain rare cases are recorded in 
which the child has actually passed through the perineum, by forcing 
a passage through this structure and the anterior wall of the rectum, 
while the posterior commissure of the vagina remained unruptured. 

Eigidity of the perineum is an affection which sometimes causes a 
very serious impediment to the completion of labor. If it be simple 
rigidity, unconnected with any lesion, and accompanied with dryness 
of the parts, the treatment applicable in the case of rigid os may be 
tried here also, for there is no doubt that in such a case, warm baths, 
tartar emetic, chloroform, or chloral hydrate, would have a beneficial 
action ; and there is no reason that we can see why, in such cases, the 



280 MANAGEMENT OF NATURAL LABOR. [CHAP. 

old -fashion eel treatment by lubricants may not be useful. But there 
are cases in which rigidity is the cause of rupture ; and when the lat- 
ter is impending, we may occasionally be justified in making a slight 
incision with a lancet, or tear with the finger-nail if possible, on each 
side, as has been practiced by some of the most distinguished accouch- 
eurs. In this case the laceration which attends the passage of the child 
is, both in direction and in extent, a matter of very little importance. 
This is an advice, however, that one is almost afraid to give to the 
inexperienced, as there is much risk of its being improperly and unnec- 
essarily resorted to. Cases in which, in the absence of structural dis- 
ease, rigidity in this situation constitutes an impassable barrier to de- 
livery are very rare; but they do occur, and, when present, may require 
free lateral incisions. The treatment of perineal laceration will be re- 
ferred to in another place. 

When the passage of the head is completed, we should ascertain if 
the cord is around the neck, and if so, it must be slipped over the 
shoulders, or pulled down so as to protect the neck from injurious 
pressure. One hand is to be placed over the fundus uteri, which is to 
be gently pressed, and followed in its descent by the hand, — a practice 
which tends to promote the speedy separation of the placenta, Unless 
there are symptoms of threatened asphyxia in the child, or circum- 
stances which demand immediate delivery, we should not in any way 
interfere in the birth of the trunk, which will be naturally effected after 
a short pause, generally counted by seconds. We must now place the 
child in such a position as will enable it to breathe freely; and, should 
efficient respiration not immediately ensue, — the best evidence of which 
is a loud cry, — it will be our duty at once to adopt such means as are 
best suited to excite respiratory action. The stimulus afforded by ex- 
posure to the external air, along with certain centric causes arising 
from deficient aeration of the blood, are generally sufficient to excite 
the muscles which contribute to the act; but, should these fail, it will 
be proper, by blowing on the face, a smart pat on the nates, or sprink- 
ling with cold water, to set the function agoing without delay. Failing 
this, the infant should be plunged into a basin of warm water, and 
cold water plentifully dashed upon it as it is removed from the bath. 
The tongue should be drawn forward, the mucus rapidly removed 
from the fauces as far as is possible, and regular attempts at artificial 
respiration persevered in so long as the slightest action of the heart 
continues. In cases of suspended animation, the cord should not be 
tied until it has ceased to pulsate, as there is a possibility, in such cir- 
cumstances, of a certain amount of placental respiration. The child is 
also threatened with asphyxia in cases where it is born along with the 
unruptured membranes, and thus remains, after its separation, en- 
veloped in its intra-uterine coverings and bathed in the liquor amnii. 
In this case the membranes must be instantly ruptured, and aerial 
respiration established. 1 

1 In this case the child is said to be born with a "caul." It is supposed to be 
indicative of good luck and prosperity, and in seaport towns the caul is carefully- 
preserved, and is believed by the credulous to be a talisman which protects the 
wearer from death by drowning. 



XVI.] LACERATION OF THE PERINEUM. 281 

The infant being born, and having given proof of its independent 
existence, our next duty is to ligature and cut the cord. The material 
to be used as a ligature is a matter of no very great moment, provided 
it be of sufficient strength, some preferring strong thread, and others 
an agent which, while it compresses efficiently, is not so incisive as the 
ordinary surgical ligature, by which the gelatin of Wharton is actually 
cut. The material preferred by the latter is strong narrow tape, of 
which the narrow red tape of national tradition affords a good example. 
The ligature should be placed about two or three inches from the um- 
bilicus, and should be drawn with sufficient tightness to prevent the 
possibility of oozing. The knuckles should be brought together, 
while the knot is being drawn, to steady the hands; for, were the liga- 
ture to snap, in the absence of this precaution, the funis might be torn 
from the umbilicus or its placental attachment, and thus give rise to 
much trouble and some risk. The reason of applying the ligature at 
such a distance from the umbilicus, is to leave room for another should 
the first fail. It is usual to apply a second ligature on the placental 
side of the first, and to cut the cord between the two ; but the advan- 
tage of the additional one consists entirely in preventing the fluid con- 
tents of the umbilical vessels from further soiling the bed-linen. In 
reference to this, Dr. Dewees, who disapproves of the application of a 
second ligature, observes that " the evacuation from the open extremity 
of the cord will yield two or three ounces of blood, which favors the 
contraction of the uterus and expulsion of the placenta." In the case 
of twin pregnancy, a second ligature should always be applied, as the 
cords occasionally communicate. The cord may be divided by a pair 
of blunt scissors, for the more the Avails of the vessels are lacerated, 
the less likely is subsequent haemorrhage to occur. 

The child being separated and handed to the nurse, there only now 
remains, to complete delivery, the third stage, or expulsion of the 
placenta. If the directions above given have been observed, and the 
fundus uteri followed by the hand, and firmly compressed at the ter- 
mination of the second stage, little difficulty will be experienced in 
regard to the speedy and satisfactory termination of the case. If we 
do not feel that the uterus is firmly contracted behind the symphysis, 
we may attempt by friction over the fundus to excite it to contraction ; 
if, on the contrary, it is quite firm, the case may be left absolutely to 
nature, when expulsion will usually occur in from ten to twenty 
minutes. But what is, in its results, a much more satisfactory method 
of procedure is to keep the hand upon the uterus, and to aid its con- 
traction by means of firm pressure. This method of expression, or 
squeezing the placenta and membranes out of the womb, has long been 
practiced by some; but, fortunately, of late years, more particular 
attention has been directed to it under the name of "Crede's method/' 
so that this mode of managing the third stage is now becoming — as it 
ought to be — very generally adopted. In this way, a very few minutes 
will usually suffice for the passage of the placenta, its ultimate emer- 
gence being effected by the action of the muscular fibres of the vagina 
and perineum. Pulling on the cord should always, if possible, be 
avoided. 



282 MANAGEMENT OF NATURAL LABOR. [CHAP. 

[Credos method of delivering the placenta is best performed by 
seizing the uterus, with the fundus in the hollow of the hand; the 
four fingers being applied to the posterior, and the thumb to the an- 
terior surface of the organ. The relaxation of the abdominal walls 
enables the physician to do this readily, so that he has the organ 
thoroughly under control. The uterus is then firmly compressed, 
when the placenta is expelled, sometimes with a gurgling noise. This 
method of delivering it is especially valuable during an epidemic of 
puerperal fever, and when the- general practitioner has under his eare 
diseases which he- fear- might be transmitted to his puerperal patient by 
inoculation. — P.] 

Should any unusual delay or special difficulty arise, it will then be 
proper to pass a finger into the- vagina, using the cord a- a guide, in 
order to ascertain whether or not the separation of the placenta is com- 
plete. When, with a single finger, we can reach with ease the inser- 
tion of the cord, we- may infer that the placenta, or at least the greater 
part of it, i- in I he vagina, and under such circumstances we may 
attempt to hook down it- edge, at the same time drawing gently on 
the cord. But when we- find the cord passing up into the uterus be- 
yond oiii" reach, the edge of the placental mass which presents at the os 
uteri being alone accessible, we- know that the placenta, although possi- 
bly completely separated, ha- not as yet been expelled from the uterus; 
and, after pausing for a few minutes, we again endeavor, by forcible 
compression applied by both hands to the fundus and sides of the 
womb — the fingers being directed to the pubes — to awaken the dor- 
mant uterine energy, to assist such pain- as may be present, or to imi- 
tate them if absent. It will be necessary, however, in a certain num- 
ber of instances, to assist nature in the- completion of the deliverance. 
An intelligent apprehension of the manner in which the placenta is 
naturally expelled, which is described in the preceding chapter, will 
prevent us under such circumstances from doing, what is too common 
in midwifery practice, viz., forcibly pulling on the cord. In a large 
proportion of cases, the delivery of the placenta may doubtless by this 
means be effected, it being hauled through like an inverted umbrella, 
hut \\\<: amount of haemorrhage, at the time and afterwards, which 
attends such a mode of procedure, is thus very unnecessarily increased. 
The proper course is to pull down the presenting portion of the pla- 
centa, using only such traction upon the cord as may assist us in effect- 
ing this object. Our first efforts of extraction should be made in the 
axis of the uterus, backwards and downwards. This is to be altered, 
as soon as the placenta passes into the vagina, to a direction down- 
wards and forwards, corresponding to the axis of that canal. Should 
we fail in this attempt, or should there be danger of a portion only of 
the placenta being removed, it will be proper to introduce cautiously 
the hand into the uterus to such an extent as may be necessary for the 
complete extraction of the mass; and, if it should then be found, as is 
sometimes the case, that morbid adhesions exist, these must be broken 
down in their whole extent, and the hand, if possible, not removed 
until the entire placenta is brought with it. Irregular contraction of 
the uterus may also prevent its expulsion, and of this a familiar variety 



XVI.] AFTER DELIVERY. 283 

is described as "hour-glass" contraction, the organ being retained in 
the upper segment by a constriction. 

When the placenta is expelled, or has been extracted, it is well to 
look at its uterine surface to see that no portion of it has been left be- 
hind ; and it is also of importance, as it escapes from the external parts, 
that the adherent membranes should pass along with it, as otherwise a 
portion of them may be torn off and left behind in the uterus. With 
this object in view, we are advised to twist or rotate the placenta as it 
is passing the vulva, the membranes being thus twined into a sort of 
rope which renders them less likely to tear. The uterus is now to be 
examined, and we must satisfy ourselves of its existence in the form of 
a firm tumor behind the pubes about the size of a child's head. The 
prepared sheet being now pulled from beneath the woman, and with it, 
as far as possible, the discharges, she may be allowed to lie on the 
back, with the legs extended and the knees together. In this position, 
the condition of the uterus may be still more satisfactorily ascertained, 
and it is a good plan in practice to place the hand of the patient 
over the uterus, and instruct her to press gently upon it occasionally, 
which insures the expulsion of any clots which may be retained, and, 
in the case of pluriparse, has an excellent effect in moderating after- 
pains. So soon as we are satisfied with the contraction of the uterus, 
and the woman has been made comfortable by the removal of the pet- 
ticoat, and rolling down of the night dress which has thus been pre- 
served from the discharges, a dry napkin is placed over the pudendum, 
and the abdominal bandage applied. The object of this bandage, the 
propriety of which has been disputed, is to afford the uterus and other 
organs some support, as a substitute for what they have lost in the 
sudden relaxation of the abdominal walls. If there is any tendency 
to haemorrhage, it is usual to fold a towel in the form of a pad, and 
place it beneath the bandage over the uterus, so as to exercise more 
direct pressure over that organ. Another and subsequent use of the 
bandage in the hands of a skilful nurse is the preservation of a woman's 
figure, a matter to her of no little importance. Bandages are often 
shaped, in which case they have sometimes a T bandage attached to 
keep the napkin in contact with the external parts. In ordinary prac- 
tice, nothing is better than a bolster cover, which, when pinned firmly 
over the abdomen, serves the purpose admirably. 

[There is considerable difference of opinion among American ac- 
coucheurs in regard to the use of the binder. During the past ten 
years some appear to be disposed to discard it. The truth appears to 
be between the extremes in this, as in many other things. Patients 
generally prefer to have a well-applied binder. It gives them comfort, 
but unless properly adjusted it does more harm than good. The bene- 
fits which follow its application are obtainable during the first few hours 
after delivery. At this time it acts in precisely the same 'manner that 
the bandage used in the operation of paracentesis abdominis does. 
After the woman has become accustomed to the changes produced by 
the discharge of the uterine contents, the bandage has done its work, 
and may be removed. The widespread opinion among women that 
it aids in restoring the original outlines of the figure does not call for 



284 MECHANISM OF LABOR. [dlAP. 

its continued use. As a rule, compresses had better not be employed, 
and the bandage should be thin enough to allow the uterus to be felt 
through it. — P.] 

So soon as the bandage has been applied, and the comfort of the 
mother otherwise attended to, the nurse is at liberty to dress and 
attend to the child. The patient must be strictly enjoined to maintain 
the horizontal position, as fatal cases have occurred in women who had 
imprudently assumed the erect posture shortly after delivery, and had 
thus established such haemorrhage as immediately proved fatal. A 
single glass of sherry or claret with water may be allowed ; but it is 
truly astonishing how seldom this is necessary, so admirably is the 
effort even of weakly women compensated for. It is advisable for the 
practitioner not to leave the house too hurriedly, until he feels confi- 
dent that all is well, and more especially, that there is no tendency to 
post-partum haemorrhage. An excellent physiological method of 
averting the latter, is to put the child early to the breast, which seldom 
fails to excite reflex uterine contraction ; and this acts otherwise ad- 
vantageously, although there is no milk in the breasts, by drawing 
out the nipples. 



CHAPTER XVII. 

THE MECHANISM OF LABOR. 

IDEAS WHICH LABOR INVOLVES — DIFFICULTY AND IMPORTANCE OF THE SUBJECT — 
HISTORICAL SKETCH : VIEWS OF SIR FIELDING OULD ; OF SMELLIE ; OF SAX- 
TORPH ; OF SOLAYRES DE RENHAC ; AND OF NAEGELE — NATURAL AND FAULTY 
PRESENTATIONS — CRANIAL PRESENTATIONS — OCCIPITOANTERIOR AND OCCIPITO- 
POSTERIOR VARIETIES — FIRST POSITION : PELVIC OBLIQUITY: OCCIPITOFRONTAL 
OBLIQUITY, OR FLEXION: THE HEAD " AT THE BRIM :" EXAMINATION OF FON- 
TANELLES AND SUTURES — ROTATION; CAUSES OF — THE "PRESENTATION," OR 
" PRESENTING POINT" — THE CAPUT SUCCEDANEUM — THE CHIN LEAVES THE 
CHEST — FURTHER DESCENT AND BIRTH OF THE HEAD — OBLIQUITY AT THE 
OUTLET — MOULDING — EXTERNAL ROTATION OR RESTITUTION OF THE HEAD — 
SECOND POSITION : THE CONVERSE OF THE FIRST — RESUME OF MECHANISM IN 
OCCIPITOANTERIOR POSITIONS. 

The primary idea of Labor comprises three secondary ideas : a body 
which is to be propelled, a force by means of which the propulsion 
is to be effected, and a passage through which it takes place. The 
mechanism of birth thus includes, in its most comprehensive sense, all 
mechanical questions which spring from the elaboration of these three 
ideas. The various points connected with the anatomy of the parts, 
and arising from a consideration of the various forces which contribute 
to effect the expulsion of the child, having been already fully discussed 
in preceding chapters, there remains still for careful study, the relation 



XVII.] PRELIMINARY CONSIDERATIONS. 285 

which the body propelled bears to the canal during the different stages 
of labor. It is in this higher though more restricted sense that the term 
Mechanism of Labor is employed, and a study of this subject includes, 
therefore, a thorough and critical examination of the physical laws 
according to which the process of parturition is in the human race 
effected. 

A knowledge of this section of the subject has been fitly described 
as the keystone of the art of obstetrics. For, without an intelligent 
apprehension of the various doctrines involved, the practice of mid- 
wifery is reduced to a mere handicraft, in which a certain amount of 
manual dexterity may be attained, but which, under such circumstances, 
is utterly unworthy of the dignity of a science. We cannot, therefore, 
too earnestly nor too emphatically, urge upon the student the necessity 
of mastering at the outset this important subject, upon which a great 
part of what is to follow is founded. It is not by any means an easy 
matter, just at first, clearly to understand the descriptions given in 
books, or to follow at the bedside the process so described. This 
demands sustained attention, and a perseverance which is apt to be 
baffled by the peculiar circumstances under which the investigation is 
conducted. We may here mention shortly what the chief difficulties 
are, and how they may in some measure be avoided. 

The most effective descriptions, and such as are most useful to the 
student, are, undoubtedly, those in which unnecessary complication is 
most scrupulously avoided, and in nothing is simplicity more essential 
than in the various classifications of labor according to the position of 
the child within the pelvis. A simple system ought, therefore, in every 
case to be preferred : in regard to such as are more complicated, it has 
been well observed that divisions and subdivisions may be multiplied 
almost at will. The chief difficulty of the beginner arises from the 
somewhat complex mental process through which alone he can deter- 
mine the presentation and position of the child in any given case, — a 
difficulty which the obstetric posture in this country somewhat increases. 
For not only have we to figure to ourselves the child with its axis 
inverted — standing, so to speak, upon its head, which is towards the 
os uteri — but we have also to allow for the posture of the woman, lying, 
as she does, horizontally, or with the long axis of her body at right 
angles to that of the accoucheur. Some of this difficulty is avoided by 
remembering that in almost all cases the right side of the child corre- 
sponds to the right side of the mother ; that its back is turned to her 
anterior or abdominal surface, and that its head is downwards in the 
direction of the os. These are the first points which it is necessary 
clearly to understand in regard to the anatomical relations of the child 
in natural labor ; but, essential as such preliminary knowledge is, it 
has no direct reference to what is known in modern times as the 
mechanism of labor. 

The facts just stated comprise well-nigh all that was formerly known 
in reference to the child during labor, and their observation led to very 
erroneous conclusions as to the manner in which its birth takes place. 
Until 1741, it was, in fact, assumed that there was no special mechanism 
of labor beyond the mechanism which attends any vital expulsive act, 



286 MECHANISM OF LABOR. [CHAP. 

and that the passage of a fecal mass or a half-organized clot was as 
little regulated by fixed mechanical laws as was the birth of the child. 
The universal belief was, that the child lay in the womb with the face 
directly backwards ; and that, in its descent through the pelvis, it 
never altered this position in its course from the brim to the outlet, 
u so that," to use the words of one of the writers of that period, "it 
seems, when she lies upon her back, to creep into the world on its 
hands and feet." As in regard to most great discoveries, so in this 
instance was the development of more correct view T s a gradual process, 
and the result of the investigations of successive observers. It was 
from first to last a process, in the case at least of those who contributed 
in any considerable degree to its advance, of close inductive reasoning, 
according to which, step by step, during a period of about eighty years, 
the subject gradually emerged from obscurity. Nothing tends so much 
to impress upon the mind the great facts which have been disclosed in 
the course of this investigation, as a narrative of the successive steps 
by which the truth was ultimately attained ; and we shall, therefore, 
here*call attention to the more important contributions which have from 
time to time been made in this direction. 

The honor of the first step in the process of demonstration is un- 
doubtedly due to Sir Fielding Child, of Dublin, who published to the 
world, about the date above mentioned, a statement to the effect "that 
the breast of the child does certainly lie in the sacrum of the mother, 
but the face does not ; for it always (when naturally presented) is 
turned either to the one side or the other, so as to have the chin directly 
on one of the shoulders." The idea here involved is the twisting of 
the neck, so as to bring the long diameter of the head into parallelism 
with that of the shoulders, the greatest diameter both of the head and 
the trunk being thus arranged so as to avoid the limited antero-pos- 
terior measurement of the brim. The step next in succession was 
achieved by Sine! lie. This excellent obstetrician, whose work is still 
deservedly ranked among the classics of English midwifery, confirmed 
Child's observation that the long diameter of the head occupied the 
transverse diameter of the brim, as it found, in that direction, the most 
ample accommodation. But to this he adds, as the result of his own 
observations, that the long diameter of the head rotates at the outlet into 
the antero-posterior diameter, which his measurements, allowing for the 
recession of the coccyx, clearly indicate as the best. In many respects, 
the views enunciated in this admirable work come much nearer the truth 
than some of a later date ; and its translation into several continental 
languages brought the opinions of the author prominently under the 
observation of the medical schools of Europe. From that time, indeed, 
no writer of note in any language has failed to pay his tribute of ad- 
miration to the importance of Smell ie's works, and the genius of their 
author. 

The work of Smellie found continental obstetrics in a most unfavor- 
able state as compared with the English school, and provoked much 
unfavorable criticism. Steadily, however, his ideas gained ground, 
although considerably disturbed by the excitement of those who joined 
with Levret in forming what we may term the geometrical school of 



XVII.] HISTORICAL SKETCH. 287 

obstetrics, and who believed with their master " that labor was a purely 
mechanical operation, and susceptible of geometrical demonstration." 
The ultimate adoption by the most able continental obstetricians of the 
views of Smellie undoubtedly preceded the brilliant results which a few 
years later were disclosed, and for which we owe them so much. It 
was admitted, as proved by Smellie, that there is a determinate relation 
between the pelvis and the child's head during the whole time of labor. 
But the point now for the first time disclosed, was that the head passes 
into the pelvic cavity, in a position which corresponds neither to the 
transverse nor the conjugate diameter, but is intermediate between the 
two, or oblique. The names of Saxtorph of Copenhagen, and Solayres 
de Renhac of Montpellier, are specially connected with the discovery 
and announcement of this fact, which was published almost simultane- 
ously by them about 1771. The discovery had, however, been made 
at an earlier period by Berger, whose pupil Saxtorph had been not later 
than 1759. Of this, indeed, there is internal evidence in Saxtorph's 
works, who, far from claiming originality, says in a note to one of his 
papers on this subject, "In a similar manner, Berger saw the true posi- 
tion of the head in labor, and imparted it in his lectures." But, how r - 
ever this may be, it is certain that, but for Saxtorph and Solayres, this 
great truth would have remained unknown, possibly even to the present 
day. We have elsewhere 1 stated and fully analyzed the views of these 
distinguished observers, at a length which is here quite impossible. 
We may state, however, in general terms, that the discovery with which 
their names will always be connected, embraces the fact that the long 
diameter of the head not only occupies in the pelvis an oblique diam- 
eter, but that it occupies in the great majority of cases the right oblique 
diameter? Solayres gives, further, an elaborate account of the mech- 
anism of labor in the different cranial positions, and in this he is fol- 
lowed by his pupil and enthusiastic admirer, the celebrated Baude- 
locque; the tendency of both writers being to run into too great elabo- 
ration in classification and description. Baudelocque seems in some 
measure to have recognized the rotation which takes place in occipito- 
posterior positions, the clear demonstration of which is certainly due to 
Naegele, and the discovery of which is generally attributed to the same 
writer. Between Baudelocque and Naegele, no name occurs, the men- 
tion of which is essential to the elucidation of the subject in question. 

In 1818, Professor JNaegele, of Heidelberg, published, on this sub- 
ject, a small pamphlet, of insignificant appearance, which was, neverthe- 
less, destined to exercise a greater influence, in regard to this question, 
on the professional mind than all the ponderous tomes of the hundred 
years immediately preceding. " No other work of equally small size," 
as Dr. Tyler Smith well observes, " ever exerted greater influence upon 
any branch of medicine than that of Naegele upon midwifery. It may 

1 The Mechanism of Parturition. London, Churchill, 1864. 

2 The student will carefully note the fact that, in this work, the two oblique di- 
ameters take their name "right" or "left" from the sacro-iliac synchondrosis 
from which they spring. This has already been stated in an early chapter, hut is 
here repeated, as unfortunately, by some writers, the nomenclature of these diam- 
eters is reversed. 



288 



MECHANISM OF LABOR. 



| ('II A I'. 



be termed, indeed, the Euclid of Obstetrics j but it will nol have exe- 
cuted its mission until every accoucheur, in each individual case coming 
before him, entirely masters the position of the foetal head. Nothing 
less than this should he aimed at by every obstetric practitioner. 
Without in any way attempting to detract from the merit of Naegele, 
a meril which will have its recognition so long as medical science has 
a name, we believe that i\\^ views promulgated by him have been too 
implicitly believed in and adopted by the majority of obstetric writers. 
The translation of his essay by Rigby, and the enthusiastic defence by 
the latter of every theory and doctrine which emanated from his master, 
produced a powerful impression ; and, in point of fact, from thai time, 
English writers have, with few exceptions, reproduced, without modi- 
fication, and as demonstrated facts, the whole of the conclusions of the 
great German obstetrician. Indeed, it is not too much to say, thai the 
view generally entertained, even by the ablest writers, amounts t<> this, 
that the subjeel had been so expounded by Naegele that there was noth- 
ing further to demonstrate, that every problem and theorem was solved, 
and that his conclusions were (o he accepted as an absolute solution of 
all the difficulties and perplexities of the past. 

Some have ventured, however, both in this country and abroad, to 
demur to this, and to assert that the matter is not yet set at rest, and 
that the ipse dixit, even of Naegele, is not to be admitted as infallible. 
And, indeed, it* we rellect as to what w:is (he state of the subjeel when 

he wrote, while acknowledging that there is that in his discoveries 

which merits all the fame which attaches to his memory, we can scarcely 

conceive it possible that one mind could so grasp all the details as to 

make chaos order, and leave no point unassailable, no question unsolved. 
In forming his conclusions, no one could be more earnest and faithful 

in his observations of nature than Naegelej but, in some respects at 
least, he was mistaken, and from some of his facts he drew erroneous 
inferences. To him is due (he whole credit of showing, although he 
exaggerates it, that the head lies in the right oblique diameter in a. 

preponderance of cases such as had never been dreamed of. I le demon- 
strated also, what vxvvy modern accoucheur has corroborated many 
times in his own practice, the rotation which naturally ocours in oc- 
ci pi to-posterior positions of the head. And he showed that, in ordi- 
nary labor, the forehead does not rotate completely into (he hollow of 
the sacrum, but still retains, in a certain degree, its oblique position. 
Finally, he asserted, and is admitted by most systematic writers to have 
proved, thai there exists, on the part of the head in its descent through 
the pelvis, a bi parietal obliquity, according to which one ear is ap- 
proximated to the corresponding shoulder. We accept, in general 

terms, all liis conclusions, with the exception of the last, to the investi- 
gation of which we have devoted much time and patience, and conclude, 

unhesitatingly, with Velpeau, Cazeaux, Matthews Duncan, and many 

others (the number of whom is constant ly increasing), that no such bi- 
parietal obliquity as Naegele described exists as a normal phenomenon 
of natural labor. 1 



1 To examine critically the views of Naegele <>n this subject would involve Hi 
introduction of controversial matter quite unsuitable to a systematic treatise. W< 



XVII.] 



PRESENTATION. 



289 



Presentations* — The term " presentation " should, as has already been 
stated, only l>e employed to express the relation which the long axis of 
the child bears to the axis of the uterus ; and should never be confounded 
with "position," which is used in another and more restricted sense. 
We speak, therefore, of presentation of the head, of the breech, of the 
shoulder, and so on, as representing the part which occupies the os uteri. 
The presentations may be multiplied to any extent, as there is scarcely 
a single point on the surface of the child's body which may not, under 
certain circumstances, oiler itself at the os. In proceeding to the con- 
sideration of the various presentations which il is necessary specially to 
describe, and remembering the attitude of the foetus within the womb, 
we recognize the Pact that il forms an irregular oval. By either end of 
this oval, delivery may take place naturally, so that we may consider 
ms Natural Presentations all the varieties known as cranial, breech, 
knee,and footling cases. When thechild lies transversely, the shoulder, 

Or some oilier part of the superior exl remil y, or, in oilier words, (lie 

side of the oval, — presents ; and, as those cases can rarely be terminated 
by the unaided efforts of nature, they may be termed Faulty Presenta- 
tions. The following Table, which is given by Dr. Churchill, will give 
some idea of the relative frequency of the various presentations, as de- 
duced from the practice of different individuals: 



Author. 


Total number 


Head Presen- 


Breech Pre- 


[nferlor 


Superior 


of Cases. 


tations. 


sentations. 


Extremities. 


Extremities. 


Mud. Boivin, . . . 


20,517 


L9.810 


872 


288 


80 


Mud. Lachapelle, . 


15,652 


14,677 


849 


K 1V> 


68 


Dr. Joseph Clarke, . 


10,887 


9,748 


61 


184 


48 


\)\. iM.'iiiiiian, . . . 


2,947 


2,786 


78 


40 


1!) 


Dr. d run villc, . 


640 


619 


•j 


8 


1 


Edinburgh Hospital, . 


2,452 


2,225 


17 


8 


4 


Dr. Maunsel, . . . 


889 


786 


— 


21 


l 


Mr. Gregory, . . . 


69] 


645 


II 


7 


1 


Dr. Collins, .... 


16,414 


15,912 


242 


is? 


40 


Dr. Boatty, .... 


L.182 


1,105 


28 


ir> 


I 


M p. Lever, .... 


4,666 


4,266 


59 


29 


12 


Dr. Churchill, . . . 


1,640 


1,119 


86 


22 


!) 


Drs. MoClintockand | 

llnrdy, .... | 


6,684 


5,815 


1 10 


r.l 


26 


Drs. Sinclair and \ 
Johnston, . . . j 


18,748 


11,874 


809 


ISI 


80 



The enormous preponderance of cranial overall oilier presentations 
renders a study of the former by far the most important. We shall, 
therefore, in the first place, direct our attention to the different varieties 
of cranial presentations. In respect of the difficulties which the student 
will encounter, in his endeavor to master this subject, i( has already 



feel, however, that Naegele's views have such a hold on British obstetrics, and d» v - 
mand, as well us deserve, such earnest consideration, that we do not oonsider our- 
selves justified in passing over with :> simple denial any statement to which he has 
lent the weight of his great authority, we reproduce, therefore, in the form of an 
A.ppendix, the reasons which have indue 

point,. (Sec Appendix.) 



P 

id ii> to rejeot Naegele'a dictum on this 



i'.» 



290 MECHANISM OF LABOR. [CHAP. 

been confessed that these are not inconsiderable. But it is only at the 
outset that real difficulty will be met with. With every case we observe, 
and every minute we devote to the subject, what seems almost insur- 
mountable at the first glance will melt away. More and more clearly, 
as we grapple with the minor difficulties which now arise, do we discern 
the great truths upon which the science and art of obstetrics depend. 
Having once fairly mastered the subject, we can never forget it, and so 
habitual and automatic will our observations become, that we shall find 
ourselves unconsciously adding to our stock of knowledge, and storing 
up valuable facts which will stand us in good stead in many an hour of 
difficulty and danger. But, if the student, at this period of his career, 
fails to acquire the requisite amount of knowledge which enables him 
to perfect the iactus eruditus, he will most likely never rise beyond 
mediocrity in obstetrical and scientific knowledge. Success after a 
fashion he may reach, but his attainments will never much surpass 
those of an intelligent midwife. Once more, therefore, we would urge 
upon the beginner, with what emphasis and earnestness we can com- 
mand, to lose no opportunity of acquiring sound knowledge on so im- 
portant a subject. Without it, the practice of midwifery is weariness 
and drudgery ; with it, it is a subject of constant interest, worthy of, 
and affording ample scope for, the highest scientific acumen. 

As the occipito-frontal or long diameter of the child's head may, in 
a presentation of that part, lie at the brim of the pelvis in the conjugate, 
oblique, or transverse diameter, or in any diameter intermediate between 
these, the number of Cranial Positions may be multiplied to any con- 
ceivable extent. Admitting the possibility of all of these, we at the 
same time recognize the fact, which Solayres de Renhac has so clearly 
demonstrated, that the occipito-frontal diameter of the head of a mature 
child enters a normal pelvis in one or other of its oblique diameters. 
This admits of but four cranial positions, depending upon the direction 
in which the poles of that diameter are turned. In two, the occiput is 
turned forwards ; and, in two, it is directed backwards : these are called 
respectively Occipito-Anteriorand Occipito-Posterior. Four positions, 
therefore, are described, which are termed First, Second, Third, and 
Fourth : 

f , r , p ... f Head in Right Oblique Diameter; 

n^ DT ™ A^„r, D j Position, | forehead backwards. 

Occipito- Anterior, ■{ ; -^ -, . T - ,,, ,. t^. 

I Second Portion ' Head in Left Oblique Diameter ; 

^ second fosiaon, ^ f ore head backwards. 

f Third Position i Head in Kight 0bli q uer>iametei ' I 
Occipito-Posterior J ' * forehead forwards. 

in ,. n -a- f Head in Left Oblique Diameter : 
forehead forwards. 



1 



[American obstetrical authors and teachers generally describe six. 
positions of the cranium, three of which are occipitoanterior and three 
occipito-posterior. They are classified as follows : 

f p . , n ., f Head in Ric;ht Oblique Diameter : 

First Position. < * -u j v 1 j 

| ' \ forehead backwards. 

~ . ! a , D ... f Head in Left Oblique Diameter : 

Occipito-Anterior, \ Second Position, | foreh ead backwards. 

Head in Antero-Posterior Diam- 
eter ; forehead backwards. 



XVII.] FIRST CRANIAL POSITION. 291 



OCCIPITO-POSTERIOR, 



Fourth Position 



>{ 



Head in Right Oblique Diameter; 
forehead forwards. 
„.,,, n ... Head in Left Oblique Diameter ; 

Fifth Position, | forehead forwar l s . 

. ,-. r, ... r Head in Antero-Posterior Diam- 

L Sixth Position, | eter . forehead forvyards.-P.] 



First Position. — The head of the child, which occupies generally, 
above the brim, a position approaching the transverse, with the face 
to the right, assumes, as it enters the pelvis, in the great majority of 
cases, what is called the First Position. The centre of the occiput is 
turned towards the ilio-pectineal eminence on the left side, while the 
forehead is directed to the right sacro-iliac synchondrosis. The long 
diameter of the head thus lies in the right oblique diameter. So soon, 
however, as the head encounters resistance in its descent towards the 
cavity, its long diameter ceases to be parallel with the plane of the 
brim, and nothing can be clearer and more obvious than the advantage 
which is thus obtained. For this occipito-frontal obliquity not only 
involves the passage of the occiput in advance of the forehead, in a 
degree proportionate to the amount of resistance, but, involving as it 
does a flexure of the neck, it thus enables the propulsive force to 
operate at a greater mechanical advantage, so soon as the chin becomes 
applied to the sternum. It is, in fact, the vis a tergo which causes the 
obliquity, as is most admirably described by Solayres in his account of 
the position which we are now considering. The propulsive forces 
which impel the foetus so situated, are communicated, in the first in- 
stance, to its vertebral column, the articulation of which with the base 
of the skull is much nearer the occipital than the frontal pole of the 
long diameter. This of itself, supposing the resistance to be equal all 
round, would be sufficient to cause the occiput to take precedence of 
the forehead ; but the movement is further encouraged by the curving 
of the spinal column through which the force is transmitted. 

No term in midwifery is more loosely used than the expression "at 
the brim." In reference to this, we observe that the head, in passing 
the brim, offers, first, the vertex, 1 then its transverse or biparietal 
measurement, and, lastly, its long or occipito-frontal diameter, so that 
although a considerable portion of the cranium has passed the brim, 
and consequently occupies the cavity, it cannot be said to have cleared 
the brim until the occipito-frontal diameter has passed. A reference 
to Fig. 102 will render this more intelligible, the line A B there indi- 
cating the biparietal plane, and that which is marked C D the occipito- 
frontal plane, w T hich cannot pass the brim until the former has de- 
scended some little way into the cavity. The occipito-frontal obliquity, 
or flexion of the head, no doubt, disturbs in some measure the idea thus 
expressed, but this, we believe, can only take place when the resistance 
is considerable, and occurs at an earlier stage than usual. We hold 
the head, therefore, to be "at the brim," in the proper sense of the 
term, when the long diameter occupies its plane; but as this can only 
be approximately ascertained, it cannot be held as a definition which is 

1 For definition of this term, see p. 136. 



292 



MECHANISM OF LABOR. 



[CHAP. 



practically satisfactory. It is better, however, than using the terra, as 
many seem to do, without attaching to it any clear meaning whatever. 



IG. 102. 




Cranial planes as they engage in the brim. 

While the head occupies the position indicated in Fig. 103, which 
we assume to be at the brim — and in which flexion has not as yet 
occurred — it is scarcely likely that what we have described as the first 
stage of labor has, as yet, terminated, or even that the os has reached 
such a degree of dilatation as to admit of a thorough vaginal examina- 

FlG. 103. 




First cranial position. 



tion. In making such an examination at this time, the first point to 
be remembered is the relation which the finger bears to the uterus and 
its contents ; for most incorrect views will inevitably be adopted if we 
overlook the fact that the axis of examination forms, with the axis of 
the uterus and that of the brim, pretty nearly a right angle. The 
part of the foetal cranium which is lowest in the pelvis, and which the 
finger first touches, is the right parietal bone in the neighborhood of 
its tuber. 1 But, if the finger be pushed farther back, so as to reach 

1 This is one of the points upon which Naegele founded his belief in the exist- 
ence of bi parietal obliquity. Our reasons for dissenting from this view are fully 
given in the Appendix. 



XVII.] ROTATION. 293 

the point on the surface of the foetal cranium through which the axis 
of the brim may be presumed to pass, we shall find that this corre- 
sponds to some point in the line of the sagittal suture, nearer to one or 
other fontanelle in proportion to the degree of flexion. 

The descent of the head is not, in the first part of its course, in a 
direction which is identical with what has been described as the axis of 
the pelvic canal. Its movement is, in fact, directly downwards and 
backwards in the axis of the brim, until it approaches the floor of the 
pelvis, and experiences the resistance to its advance arising from the 
gradual approximation of the ischial planes. Upon the degree of 
flexion depends entirely the extent to which the occiput is in advance 
of the forehead. The further dilatation of the os uteri, and the rup- 
ture of the membranes, now usually admit of more exact observation 
by the finger, by which the sagittal suture will be found traversing the 
pelvis obliquely in the right oblique diameter. In the posture in 
which the woman is lying, therefore, we trace this suture downwards 
and forwards for a short distance, to a point within easy reach of the 
finger, where it divides into two branches. This indicates the posterior 
fontanelle, which the pressure generally renders indistinguishable as a 
fontanelle by approximation and overlapping of the bones. The two 
branches are the lambdoidal suture. Following the sagittal suture in 
the contrary direction, and with reference still to the posture of the 
patient, the finger travels upwards and backwards towards the right 
sacro-iliac synchondrosis. It requires some effort to reach the anterior 
fontanelle, not only on account of its being situated posteriorly in the 
pelvis, but on account of the flexion, which removes it farther from 
our reach. Very generally, it can only be reached by subjecting the 
woman to some pain ; but it is easily recognized by its size and shape, 
and by the four sutures which run into it. If the right ear can be 
reached behind the symphysis without causing unnecessary suffering, 
the direction of its lobe at once reveals the position of the head. 

In consequence chiefly of the approximation of the sides of the pelvis 
which has been mentioned, the head now undergoes a change in its 
position. This is effected by the movement which was described by 
Smellie, and which is known as the rotation of the head. This rota- 
tion, which is effected gradually, brings the antero-posterior diameter 
of the head into, or nearly into, the conjugate of the pelvis, so that the 
occiput looks forwards to the subpubic angle, and the forehead back- 
wards to the hollow of the sacrum. The recession of the anterior lip 
of the os beyond the advancing head admits of an easy examination of 
this process, which an observer may demonstrate for his own satisfac- 
tion by keeping his finger for a time in contact with the head. As he 
does so, he will often observe, as the head advances and recedes with 
successive pains, that the degree of rotation is greatest at the height of 
a pain, while, as the pain passes off, the head resumes its former posi- 
tion. The movement may thus be compared to that of a screw, the 
action of which is alternately direct and reversed. That nature pro- 
vides for this rotation of the head in labor is made manifest by an ex- 
amination of the relative measurements of the brim, cavity, and outlet 
of the pelvis. A question which has given occasion for much specula- 



294 MECHANISM OF LABOR. [CHAP. 

tion is the mechanical cause of the rotation. The head, if maintaining 
its original direction, would simply be arrested at the outlet of the 
pelvis, its further progress, if of average size, being impossible. In 
virtue of what law, then, does it so invariably rotate ? 

Some have professed to recognize in the womb itself a rotatory power 
(vis vertens) by means of which the rotation of Smellie was effected. 
Others have studied most industriously the mode of action of the 
various muscles which line the pelvis, believing that in this direction 
the solution of the problem is to be found ; and by one accoucheur of 
eminence — Flamand of Strassburg — it was supposed that the action of 
the obturator internus and piriformis muscles was the cause upon 
which the phenomenon in question depends. Modern investigation 
has r however, proved that it is due to the nature of the opposing force 
which exists at the floor of the pelvis. If we look at the internal 
lateral surface of the pelvic cavity, as it is here represented, we observe 
that the tip of the ischial spine is the point which encroaches farthest 
upon the transverse measurement of the pelvic canal. The head, 
therefore, as it descends in the right oblique diameter, in the position 
which we are now studying, arrives at the floor of the pelvis with the 
occiput in front of the left ischial spine, and, as a consequence, the 
forehead behind the right spine. Rotation backwards of the occiput 
or forwards of the forehead is thus effectually prevented. As the pro- 
pulsive stage advances, the occiput is conducted downwards and for- 
wards by the inclined plane formed by that portion of the ischium 
which is in front of and inferior to its spine, and by the obturator in- 
ternus muscle ; while on the other side of the pelvis, and on a higher 
level, the forehead is directed by the yielding sacro-sciatic ligaments 
towards the hollow of the sacrum. These two surfaces, then, are in- 
clined planes which constitute the female screw, while the male screw 
is represented by the child's head ; and we fully agree with Dr. Tyler 
Smith, that "the key to the pelvic mechanism, in an obstetric sense, 
may be said to be the spinous processes of the ischia." Some writers, 
it may be here observed, describe a posterior inclined plane of the 
ischium, which is separated from the anterior by an imaginary line 
leading from the spine of the ischium in the direction of the ilio-pec- 
tineal eminence. (See Fig. 15, p. 44.) This they suppose to act, in 
reference to the forehead, as the anterior plane does with the occiput. 
No such action can, however, be performed by this plane, as the fore- 
head impinges upon the spine and margin of the great notch, and is at 
once conducted to the ligaments along which it glides. 

We have already used the term " Presentation " in its broader signi- 
fication. There is, however, another sense, in which it is employed by 
all British and American obstetricians, which here calls for some spe- 
cial notice, as there unfortunately obtains, in regard to this, as well as 
other terms in English midwifery, the objection that each writer is left 
to attach to it his own meaning. The presentation, in the second and 
more limited sense, is not the part of the child but the actual " point " 
on its surface which presents ; and, if it be wished to express this cor- 
rectly, we do not know of a more accurate definition of the term than 
that given by Professor Hodge of Philadelphia, who describes it as 



XVII.] 



OSCILLATION OF THE HEAD. 



295 



- that portion of the foetal ellipse which is recognized toward the centre 
of the canal of the pelvis and vagina." This is practically the same as 
that of Dr. Matthews Duncan — " that point on the surface of the 
child's head through which the axis of the developed pelvic canal 
passes." But, while admitting these to be mathematically more cor- 
rect, we must own to a preference for the meaning which is attached 
to the word by Dr. Tyler Smith, who defines it as " that portion of the 
foetal head felt most prominently within the circle of the os uteri, the 
vagina, and the ostium vaginae, in the successive stages of labor." 
When the dilatation of the os uteri proceeds with unusual slowness, 
owing to rigidity, or premature rupture of the membranes, the caput 
succedaneum forms upon the scalp. Under such circumstances, that 
swelling will be found to occupy, altogether or mainly, the right pari- 



FiG. 104. 



Fig. 105. 




Internal lateral surface of pelvis. 



etal bone. This is, however, no evidence of biparietal obliquity, as 
the swelling occurs in obedience to the laws of gravity, in the direction 
of the vagina, where the resistance is least. It is only, however, under 
circumstances of exceptional resistance, that the swelling alluded to 
becomes developed at this stage. 

While the head is undergoing the rotatory process above described, 
no change whatever takes place in the parallelism which exists between 
its transverse diameter and the plane of the brim. Qua the cavity of 
the pelvis, the right side is certainly lower, but this is a very different 
matter from what is asserted by the followers of Naegele. 1 So soon as 



1 This is roughly indicated in the diagram here given. Fig. 105 shows the great 
amount of lateral obliquity, in reference to the horizon, of the head advancing in 
the first position in the axis of the brim, the centre of the sagittal suture being 
exactly midway between the promontory of the sacrum and the symphysis pubis. 
It shows, also, how, during the whole of this stage of labor, the right parietal pro- 
tuberance may be described, in general terms, as the part which first meets the 



296 MECHANISM OF LABOR. [CHAP. 

a certain amount of rotation has occurred, the vertex descends quite to 
the floor of the pelvis. The head now becomes exposed to a set of 
forces quite distinct from those which have, up to this time, been the 
sole cause of its movements. The tissues which form the floor of the 
pelvis, although they yield, to some extent, before the advance of the 
head, constitute by their resiliency an opposing force which, while it 
effectually bars the further advance of the head in that direction, deter- 
mines a motion which is the resultant of this and the force from above, 
and, being intermediate in its direction between these, is consequently 
downwards and forwards. Solayres called this a reflected force, and 
describes the mechanism in the following graphic terms : " Hujus 
motus rationem haud immerito contuleris cum ea, quse nucleus pre- 
mentes digitos fugit." An illustration of this is familiar to every 
schoolboy who has propelled a cherry-stone fresh from the fruit, by 
pressing it between his fingers. 

As the forehead of the child has, in its course along the back part of 
the cavity, to traverse a curve which is of much greater extent than 
the posterior surface of the pubis, we would anticipate what actually 
does take place, — viz., that the chin, before the completion of the 
movement of rotation, leaves the breast, and that the anterior pole of 
the occipito-frontal diameter descends, as regards the brim-plane, con- 
siderably in advance of the other, — this motion being again reversed, 
at a more advanced stage, as we shall see presently. The successive 
changes which thus occur in the obliquity of the long diameter are 
well expressed by Dr. Murphy, when he says that the head may, in 
the course of labor be described as "oscillating on its transverse 
measurement." 

From the time at which the head comes under the influence of the 
reflected force of Solayres, its general direction is altered, and now cor- 
responds pretty closely with the axis of the vagina. The vagina, or 
what, in its altered anatomical relations, we may more appropriately 
call the lower portion of the parturient canal, has a curve for its axis, 
which we have already demonstrated (p. 42) as continuous with the 
axis of the bony pelvis. The general direction of this is downwards 
and forwards, so that the head may be assumed now to move in a 
direction which forms an approach to a right angle with its original 
course. The pressure of the head upon the perineum gradually effects 
the dilatation of the terminal portion of the canal. The left division 
of the os frontis, in the immediate vicinity of the fontanelle, or the 
contiguous portion of the parietal bone, presses upon the coccyx, which 
moves backwards to the extent of an inch, in order to permit of the 
passage of the child. If the pelvis is at all under the average in point 
of size, the frontal region is arrested at the apex of the sacrum, and the 
occipital end of the lever is again driven downwards, so as to press 

finger, or as lowest in the pelvis, advancing, as it does, in the direction of the 
dotted line, parallel to the axis of the brim. If the head were in the transverse 
position, the sinking of the parietal protuberance would be still more decided. 

A B. The plane of the brim, meeting the horizon at an angle of 60° at A. 

CD. The axis of the brim, passing through the centre of the sagittal suture and 
the coccyx, and meeting the horizon at D, at an angle of 30°. 



XVII.] THE HEAD AT THE OUTLET. 297 

upon and distend the perineum. If, however, the parts be ample, and 
the perineum not unduly resistant, this does not occur, and the whole 
bulk of the head follows the curve of the sacrum at every pain, obviously 
attempting to effect an exit immediately under the pubic arch. 

From the above description, it is apparent that the occipito-mental 
or longest diameter of the child's head is never at any time thrown 
across the pelvis. The moment now approaches, however, at which a 
new movement must be executed, that of extension, and it is difficult 
at first to see how this can be effected without the extreme diameter 
being turned into the conjugate of the outlet. Nature fortunately does 
not attempt this movement until the occiput is passing upwards in 
front of the symphysis pubis in the act of birth. The motion of exten- 
sion is the reverse of the flexion which has been mentioned as one of 
the earlier mechanical phenomena of labor. The oscillations which 
the head in its course undergoes on its transverse axis are — first, flexion ; 
then partial extension prior to rotation ; then flexion, if the forehead 
be arrested at the apex of the sacrum ; and finally, the movement of 
exaggerated extension, which is only completed with the birth of the 
head. The occipito-mental diameter is not at any moment thrown 
across, and is only released when its occipital pole is born. The occi- 
put, vertex, forehead, face, and chin successively sweep over the dis- 
tended perineum, the head continuing its curved axis of motion, and 
being born upwards and forwards in front of the mons veneris. 

Before Naegele wrote, it was universally believed that the head was 
born with its antero-posterior measurement accurately corresponding 
to the conjugate diameter of the outlet. A considerable number of 
modern obstetricians still hold this view, and it is certain that, in a 
large number of instances, the head is so born. The Heidelberg pro- 
fessor taught, however, that the head did not pass into the world after 
this fashion, but that there existed at the outlet a certain amount of 
pelvic obliquity, as the forehead did not rotate altogether into the 
hollow of the sacrum ; and he showed, in addition, that a certain 
degree of biparietal obliquity is maintained, according to which the 
right parietal protuberance is, in the first position, born in advance of 
the left, so that the caput succedaneum is at this stage formed upon 
the superior and posterior quarter of the right parietal bone, close to 
the posterior fontanel le. That both of these obliquities generally occur, 
in what we may call a typical case of normal parts and moderate peri- 
neal resistance, we believe; but, in asserting that they are essential phe- 
nomena, such as are the movements of Flexion, Rotation, and Exten- 
sion, the celebrated author committed an error which his followers have 
but too faithfully copied. For these obliquities are of comparatively 
trifling importance, and should never have been bracketed with the 
other and really important movements. Until he has fully mastered 
the latter, we should advise the student to take no note of these obliqui- 
ties. The most recent writers on the subject (Kuneke, Hodge, and 
Duncan) all dispute the conclusions of Naegele and argue in favor of 
the parallelism, or, as they term it, " Synclitism," of the biparietal 
and cervico-bregmatic planes of the child's head, with the planes of the 
pelvis and the vagina. With reference to the observations of Professor 



298 



MECHANISM OP LABOR. 



[CHAP. 



Hodge, it may be remarked that he, his celebrated predecessor Dewees, 
and, we may add, the American obstetrical school generally, have long 
repudiated many of the doctrines of Naegele which are still taught in 
English text-books. Fig. 106 shows the relation which the head, 
when about to pass in this position, bears to the pelvic structures. 




The head approaching the outlet. 
First position. 



First position as seen from above. 
(Schultze.) 



No sooner is the head born than another rotation takes place, — the 
face of the child turning spontaneously to the right thigh of the mother. 
This is due to the manner in which the shoulders descend. In Fig. 
107 we are looking downwards into the cavity of the uterus. It will 
be observed that the broad, or transverse, diameter of the shoulders 
and of the breech occupies the left or opposite oblique diameter to that 
in which the anteroposterior measurement of the head is descending. 
Upon the birth of the head, the shoulders encounter the same difficulty 
from the ischial spines ; and, as the rotation must be such as to bring 
the anterior shoulder, as it did the occiput, under the pubic arch, the 
left, or posterior shoulder revolves into the hollow of the sacrum. This 
movement of the shoulders takes place, therefore, in a direction which 
is the re verse of the previous rotation of the head; so that we may 
with perfect propriety, look upon the head as resuming the oblique 
position which it originally held in reference to the pelvis. It has, on 
this account, been well called the movement of Restitution. There is 
another phenomenon which should not here be overlooked, inasmuch 
as it exercises no inconsiderable influence on the progress of labor. This 
is the moulding of which the head is susceptible, without any risk to the 
child. The amount of moulding is, of course, proportionate in a great 



XVII.] 



SECOND CRANIAL POSITION. 



299 



measure to the resistance, but the head, when born, presents in every 
instance, a shape which gives it a peculiar, elongated appearance, and, 
in cases where the caput succedaneura is much developed, this is still 
further exaggerated. The moulding and pointing of the occipital region 
is the Hinterhaiqrtspitze of the Germans ; and the form presented is, 
as will be shown in the sequel, very different from that which is pro- 
duced in occipito-posterior positions. As soon as the shoulders have 
escaped, the mechanical difficulties of delivery may be said to have ter- 
minated ; for the extent to which the parts have been dilated during 
the birth of the head, will have rendered them more than sufficient for 
the egress of the parts which remain. The Placenta escapes edgewise, 
folded as formerly described, and not inverted, as is usually asserted. 

We have, in the above description of the first position, gone pretty 
fully into detail, in order that the other three positions may be more 
easily understood. We would recommend the student, before attempt- 
ing any practical investigation of the facts which have been set forth, to 
follow the description with the bones in his hand, — by which means 
only can he thoroughly understand the subject, to the extent which is 
essential as a preliminary to the intelligent examination of the phe- 
nomena of actual labor. 

The figure here shown indicates, diagrammatically, the various posi- 
tions which the child occupies during the successive stages of labor, as 

Fig. 108. 




Diagrammatic representation of successive stages of the first position. 

just described. The representation is supposed to be of a woman from 
whose body the right half has been removed, leaving the foetus alone 
untouched. 

Second Position. — This is the converse of the First. As the head 



300 



MECHANISM OF LABOR. 



[chap. 



enters the brim of the pelvis, the occiput is turned towards the right 
ilio-pectineal eminence, the forehead being directed to the left sacro- 
iliac synchondrosis. This, therefore, like the first, is an occipito- 
anterior position, the only difference being that it occupies the left 
oblique diameter instead of the right. It is the left side of the head 
which presents, and the neighborhood of the left parietal protuber- 
ance is, therefore, the part which the finger first reaches in a digital 
examination. The sagittal suture corresponds to the left oblique 
diameter, so that when the woman is on her left side, the finger passes 
upwards and forwards, to reach the posterior fontanelle, and down- 
wards and backwards to reach the anterior. The occipital pole of the 

Fig. 109. 




Fig. 110. 




Second cranial position. 

antero-posterior diameter of the child's head is, as in the first position, 
driven downwards in advance of the other. It glides, during the ro- 
tation w r hich succeeds, in a direction downwards and forwards, along 
the ischial plane on the right side, towards the subpubic arch, while- 

the forehead moves from left to 
right, along the left sacro-sciatic 
ligaments, towards the hollow of 
the sacrum. The head, after com- 
plete rotation and sufficient dis- 
tension of the perineum, ap- 
proaches the orifice of the partu- 
rient canal, in a position which 
generally approximates that shown 
in the annexed figure (Fig. 110), 
in which a certain amount of left 
obliquity still exists, and the left 
parietal protuberance is a little in 
advance. The face, upon its birth, 
turns tow r ards the left thigh of the 
mother, while the shoulders, after 
passing the brim in the right 
oblique diameter, are rotating so 
as to bring the left shoulder under 

Second cranial position at the outlet. tne V U ® lG arc h- 



XVII.] RECAPITULATION. 301 

With reference to this external rotation of the head, it must here 
be remarked, — and the observation applies equally to first and second 
positions — that the rotation described, in each case, while the rule, is a 
rule which admits of exceptions. It is, no doubt, true, that an obser- 
vation of the external rotation of the head may generally be received 
as evidence — confirmatory, or the reverse — of the diagnosis which we 
may previously have formed as to its position in the pelvis. But 
this is by no means invariable, as sometimes, in undoubted first posi- 
tions, the face rotates to the left, and in second, to the right ; the 
direction of the movement in each of these cases being a continuation, 
by the shoulders, of the same screw motion previously performed within 
the pelvis by the head. Occasionally, as Naegele admits, and probably 
in cases where the diameters are greater than usual, the shoulders pass 
in the transverse diameter, and there is no rotation at all ; while in 
cases rarer still, as is described by Schmitt, "the face of the born head 
turns itself, first to the one side and then to the other, as if to ask of 
nature in what direction the descent of the shoulders could best take 
place." 

Once more let us recapitulate the various movements which the head 
undergoes in the two Occipito- Anterior positions above described, and 
note very briefly their mode of action as mechanical aids to labor. 

The general direction followed by the head of the child from the 
brim to the floor of the pelvis, is that of the axis of the brim. The 
longer diameter of the oval formed by the head occupies one or other 
oblique diameter, as it finds in these the longest measurement. 

By the antero-posterior obliquity of the head, not only is the occipito- 
mental diameter prevented from lying, by any possibility, across the 
pelvis, but the occipital pole of the occipito-frontal is so depressed that 
a further and obvious mechanical advantage is gained. This is other- 
wise called Flexion of the head. 

Rotation is a movement of the head upon its perpendicular axis, 
according to which its longer diameters are moved into, or nearly into 
the conjugate of the pelvis, which is at this stage the most ample. This 
is mainly effected by the anterior ischial planes, and the yielding of the 
sacro-sciatic ligaments. 

The movement of extension is that which occurs at the moment of 
birth, its most important object being to admit of the passage of the 
great occipito-mental diameter without injury to the perineum. It is, 
like flexion, a movement of the head on its transverse diameter. The 
chin leaves the sternum of the child as it descends through the pelvis, 
a certain amount of flexion again occurring if there is much resistance 
at the apex of the sacrum, but it is only when its head is passing the 
external parts that the exaggerated movement occurs to which the name 
Extension has par excellence been given. The general direction of the 
movement, from the time the head reaches the floor of the pelvis, is 
downwards and forwards, but the head follows the parabolic curve of 
the axis of the passage. 

The obliquity (pelvic) of the head at the outlet is probably due to 
the position of the shoulders ; the biparietal obliquity is accounted for 
by the head still retaining something of its original parallelism to the 



302 MECHANISM OF LABOK. • [CHAP. 

plane of the brim. Neither is of much importance, but the latter, by 
permitting one parietal protuberance to precede the other, diminishes, 
to a slight degree, the circumferential measurement of the ostium 
vaginae at the moment of its greatest distension. 

The external rotation of the head is caused by the rotation of the 
shoulders in the opposite oblique diameter to that which was occupied 
by the head. As the result of this is to restore the head, by a move- 
ment on its perpendicular axis, to its original position, it has been 
called the movement of Restitution. 

[Third Position. — The occipito-pubic position is very rare, but Ma- 
dame Boivin, Radford, Dewees, Hodge, and others have met with 
examples of it. The occiput is found directly behind the pubis. "When 
the head presents in this position, its cervico-bregmatic diameter is 
in the conjugate, and the biparietal in the transverse diameter of the 
brim. The occipito-mental of the child's head, as in the other cranial 
positions, coincides with the axis of the brim. In most cases this posi- 
tion is spontaneously converted into a first or second, owing to the 
projection of the lumbar vertebrae and upper portion of the sacrum. 
If this does not occur, the first pains produce flexion of the head, im- 
mediately after which descent commences. The biparietal diameter 
will readily pass through the transverse of the pelvis, but as there is 
but little difference between the cervico-bregmatic of the child's head 
and the conjugate of the Superior Strait, this may occasion some delay. 
When the head has once passed the brim, however, the progress is com- 
paratively rapid, as no rotation is necessary. The occiput takes its posi- 
tion under the arch of the pubis, after which the mechanism of the birth 
of the head is the same as in the first and second positions after rota- 
tion has occurred. 

There may be some delay in the birth of the shoulders, as these are 
apt to occupy a transverse position in the cavity of the pelvis, and their 
wide diameter to be consequently opposed to the short diameters of the 
outlet. Finally, however, one shoulder rotates and comes forward under 
:he arch, after which the labor proceeds as in a first or second posi- 
tion.— P.] 



XVIII.] THIRD CRANIAL POSITION. 303 



CHAPTER XVIII. 

MECHANISM OF LABOR (Continued). 

OCCIPITO-POSTERIOR POSITIONS — THE THIRD CRANIAL POSITION; ROTATES INTO 
THE SECOND, OR MAY TERMINATE WITH FOREHEAD FORWARDS — THE FOURTH 
POSITION; ROTATES INTO THE FIRST, OR MAY TERMINATE WITH FOREHEAD 
FORWARDS — ARTIFICIAL RECTIFICATION OF THESE POSITIONS — COMPARATIVE 
FREQUENCY OF THE FOUR CRANIAL POSITIONS. 

FACE PRESENTATIONS — DISTINCTION BETWEEN "OBSTETRICAL" AND "ANATOM- 
ICAL" FACE — MENTO-POSTERIOR AND MENTO-ANTERIOR VARIETIES — FOURTH 
POSITION : MECHANISM OF — THIRD POSITION — FIRST POSITION ; ROTATES INTO 
THE FOURTH — SKCOND POSITION; ROTATES INTO THE THIRD — RELATIVE 
FREQUENCY OF FACIAL POSITIONS — OPERATIVE INTERFERENCE IN — IRREG- 
ULAR PRESENTATIONS — TABULAR COMPARISON OF CRANIAL AND FACIAL 
POSITIONS. 

In the two remaining, or Occipito-Posterior positions, the head lies 
as in the former, in one or other of the oblique diameters, so soon 
as it fully occupies the brim. The reversal, however, of the frontal 
and occipital poles of the long diameter of the head here renders 
necessary the application of mechanical principles, which in some 
respects differ very widely from those which have been explained as 
accounting for the phenomena attendant upon delivery in the occipito- 
anterior positions. This becomes to some extent obvious upon an 
examination of the cranium itself, and by a comparison of the broad 
unyielding forehead with the pointed compressible occiput. But, if we 
observe further the relation which the pelvic cavity bears to possible 
movements of flexion and rotation, it will at once become apparent that 
in these positions nature has difficulties to overcome in comparison 
with which those attending the occipito-anterior positions are probably 
trifling. What these special difficulties are, we shall attempt to show, 
noting carefully, at the same time, the means which nature adopts to 
overcome the impediments which thus arise. 

Third [Fourth P.] Position. — The head in this case enters the brim 
of the pelvis in the right oblique diameter, with the forehead turned 
towards the left ilio-pectineal eminence, and the occiput to the right 
sacro-iliac synchondrosis, as shown in the accompanying figure. On a 
digital examination, it is the left parietal bone which the finger touches, 
in the neighborhood of its protuberance, at a point usually a little an- 
terior to that reached in the second occipito-anterior position. With 
reference to the posture of the woman, the sagittal suture is traced 
downwards and forwards, where it ends in the large lozenge-shaped 
anterior fontanelle; while, in the contrary direction, it may be followed 



804 MECHANISM OF LABOR. [CHAP. 

upwards and backwards to where it terminates in the posterior fonta- 
nelle. This point is of paramount importance in the diagnosis of the 
position, for when, in any case, we find that the great fontanelle is 
within easy reach of the examining finger, our suspicions should at 
once be excited, and the nature of the position carefully ascertained. 

So soon as the head becomes engaged in the brim, one of two things 
may occur. In the one case, the occiput is driven, by the propulsive 
force communicated through the spinal column, downwards in advance 
of the forehead, as in occipitoanterior cases ; in the other, the occiput 
is arrested, and the force being thus transferred to the frontal pole of 

Fig. 111. 




Third cranial position. 

the long diameter, that pole precedes the other in its descent. Whether 
the forehead or the occiput thus descends, there is, in the great majority 
of cases, no barrier to the termination of the labor by the unaided 
efforts of nature, although such cases are more or less protracted. 
When the head, therefore, is placed in the third position, the labor may 
terminate in two ways, either by rotation into the second position, or 
by the forehead passing under the pubis. As the former is the rule, 
and the latter a somewhat rare exception, we shall first consider the 
mechanism according to which, in the great majority of cases, such 
labors terminate. 

The natural termination of the third position is by a movement 
which in extent far exceeds the ordinary rotation of the head. The 
facility with which this occurs depends in no small measure upon the 
capacity of the pelvis. For nothing is more essential as a preliminary 
to this movement, than an easy descent of the occiput in the direction 
of the right sacro-sciatic ligaments; whereas, any difficulty which may 
exist, from peculiar formation, or contraction of any of the diameters, 
by arresting this initiatory movement, favors the descent of the fore- 
head. The more marked the flexion of the head, therefore, and the 
nearer the posterior fontanelle to the examining finger, the greater is 
the confidence with which we anticipate a natural and satisfactory 
rotation. If, as is frequently the case, the head descends quite to the 
floor of the pelvis before rotation has occurred, depression of the occiput 
and corresponding recession of the forehead are still the signs which 



XVIII.] THIRD CRANIAL POSITION. 305 

point towards rotation. For, in this situation, the forehead, which 
occupies the anterior inclined plane of the ischium on the left side, 
cannot, on account of the approximation of the ischial spines, rotate 
directly in the same pelvic plane. It is essential, therefore, that the 
forehead should be elevated above the spine of the ischium, and the 
antero-posterior diameter of the head thus shortened in reference to the 
pelvic planes. This is precisely what is effected by flexion at this 
stage ; and if we watch the process with the finger, we observe, in the 
first instance, that the anterior fontanelle recedes from our finger in the 
direction of the horizontal ramus of the pubis. The posterior fonta- 
nelle descends and comes within easy reach, until the flexion is so 
complete that the occipito-mental diameter approaches the axis of the 
brim. A rotatory or screw motion of the head now becomes manifest, 
the forehead moving upwards and backwards on the left, and the 
occiput downwards and forwards on the right side of the pelvis during 
a pain ; and the head resuming its former position during the interval. 
Presently, and often in the course of a single pain, it performs a rota- 
tion equal in extent to the quadrant of a circle ; and if we now make 
an examination, we find that the head occupies what was described in 
the last chapter as the second cranial position. In its normal and 
natural course, therefore, the third position rotates into the second. 

The rotation thus effected is remarkable not only in regard to the 
extent, but also in respect of the mechanism by which it is effected. If 
the mechanism were identical with what obtains in the occipito-anterior 
varieties, the forehead would, in every case, be directed by the ischial 
spine over the left ischio-pubic ramus towards the subpubic arch. But 
the mechanical result of pressure transmitted through the vertebral 
column is the same in all cases where the pelvic resistance is equal on 
all sides. The occiput being thus pressed down, the forehead. rises as 
has been described, and the chin is approximated to the sternum. A 
point is presently reached at which the whole forehead has risen above 
the level of the ischial spine, and the rotatory movement commences. 
The occiput, on the other side, is beneath the right spine, and approaches 
the centre of the pelvis, being directed downward and forwards, on the 
right side, by the corresponding margin of the sacrum and coccyx, and 
the sacro-sciatic ligaments. This is probably the cause of the first 
effort at rotation, but as soon as the forehead passes sufficiently far back 
to impinge upon the posterior ischial plane, it at once glides along this 
to the sacro-iliac synchondrosis, and the rotation is complete. After- 
wards — the presenting point being as before a portion of the left parietal 
bone — the case goes on as if it had been from the first a second position, 
the only difference as affecting the progress of the labor being that that 
process has now to commence — should it be required — which consists 
in moulding of the parts, and which, under other circumstances, would 
already have been in some measure effected. From what has been said, 
it will be understood that the earlier and the more easy is the descent 
of the occiput, the more uninterrupted and satisfactory is the course of 
the labor : in such cases there is in fact no special difficulty, and no 
additional danger either to mother or child. But, in cases in which the 
forehead continues to descend, the difficulty of rotation is greatly 

20 



306 MECHANISM OF LABOR. [CHAP. 

enhanced, for in that case the preliminary flexion involves the necessity 
of the occipitofrontal diameter being thrown across the pelvis; and if 
the measurements generally are small, this can only be effected with 
considerable difficulty, a difficulty which is increased by a certain degree 
of moulding, and the formation of the caput succedaneum in an unusual 
situation. But, even these cases will usually terminate as second posi- 
tions, more especially if a certain amount of assistance be afforded in a 
manner to be hereafter described. 

In a small proportion of cases, but certainly much more frequently 
than Naegele and his followers would have us suppose, the rotation 
above described does not take place. The forehead, in these instances, 
sinks ' low T er and lower in the pelvis, and the anterior fontanelle 
approaches still more closely to the ostium vaginae. A very useful 
practical distinction was drawn by Dr. Uvedale AY est, of Alford, a 
veteran practitioner, who has devoted much earnest thought to the 
subject now in question. Dr. West, recognizing the flexion of the head 
as an essential element in rotation, proposed that those cases in which 
the frontal pole of the long diameter remains high, all of which end by 
rotation, should be called bregmato-cotyloid, while the others, which 
terminate, or threaten to terminate, with the forehead forwards, should 
be designated fronto-cotyloid, — a simple distinction of unmistakable 
importance. 

When the head assumes this fronto-cotyloid position in a well- 
marked degree, we may be pretty sure that it will end with the fore- 
head forwards instead of the occiput. But we must not too hastily 
adopt this conclusion, as cases have been observed in which, at the last 
moment, when the part presenting had already shown itself at the 
external aperture, the forehead spontaneously moved up, and delivery 
was effected, after rotation, in the usual way. The attention of the 
accoucheur, should he have omitted to notice it previously, may be 
attracted by the fact that the labor is progressing in an unsatisfactory 
manner, and that the progress made is quite out of proportion with the 
expulsive force; and, on examination, he now recognizes the nature of 
the case with which he has to deal. At this time, the orbits and nose 
may be easily felt behind the pubis, and as labor progresses the fore- 
head comes into view. Cazeaux says that the superciliary arch may 
sometimes be seen, and that on one occasion he saw the upper eyelid. 
Under the influence of powerful uterine contraction, the occiput is now 
driven downwards, the head executing thus tardily its movement of 
flexion. The perineum becomes distended to a dangerous extent by 
the posterior part of the head. This cannot be relieved, as in the 
ordinary position, by the movement forward of the occiput, to which 
the forehead offers no resemblance in shape. The presenting part 
moves, therefore, somewhat upwards, and to the left, until the occiput 
passes over the strongly distended perineum. The final movement is 
performed by an extension of the head — the nape of the neck, pressed 
against the anterior margin of the perineum, being the centre upon 
which the revolution occurs which brings the forehead, nose, mouth, 
and chin, successively from beneath the pubic arch. The motion at 
this point is precisely analogous to what obtains in first and second 



XVIII.] 



THIRD CRANIAL POSITION. 



307 



positions, where the centre of the motion is the subpubic angle, and 
the forehead and face sweep forward over the perineum. There is 
certainly in all such cases an increased risk of perineal laceration. The 
various stages in the mechanism of delivery in this position are shown 
iii the accompanying diagram. (Fig. 112.) 

Another possible termination of occipito-posterior positions consists 
in a movement of extension, or rotation of the head on its transverse 
axis, by which the case is changed into a presentation of the face. And, 



Fig. 112. 




Fronto-anterior termination of the third position. 



moreover, as a rotation such as this would bring the chin forwards — 
which is, as we shall show, in a face presentation, a quite favorable 
position — we may assume that such an occurrence would be rather a 
favorable termination than otherwise to the cases which Dr. West 
terms fronto-cotyloid. 

Fourth [Fifth P.] Position. — The head, in this position, enters the 
brim of the pelvis in the left oblique diameter. The forehead is turned 
towards the right ilio-pectineal eminence, and the occiput to the left 
sacro-iliac synchondrosis, as shown in Fig. 113. On a digital exami- 
nation, it is the right side of the head which the finger touches. The 
sagittal suture, in reference to the posture of the woman, is traced down- 
wards and backwards to where it terminates in the posterior fontanelle, 
while, in the contrary direction, the finger follows it upwards and for- 
wards to the anterior fontanelle. The opinion is very generally enter- 
tained that, in the fourth position, the engagement of the head is more 
difficult, and its rotation slower than in the third. It is impossible to 
avoid the conclusion that this is due, in a great measure, if not entirely, 



308 



MECHANISM OF LABOR, 



[CHAP. 



to the rectum, which, by encroaching upon the left oblique diameter, 
renders it less capacious than the right. The fourth position being the 
converse of the third as the second is of the first, we find the descrip- 
tion of the one will serve, mutatis mutandis — reading right for left, and 



Fig. 113. 




Fourth cranial position. 



so forth — in every respect for the other. It may thus terminate in two 
ways, according as the occiput or the forehead descends. In the former 
case, the occiput passes below the left, and the forehead above the right 
ischial spine, so that the fourth position rotates into the first in the natural 

and normal course of such a case, 
and ends with the occiput under 
the pubic arch as usual, the right 
side of the head thus being, during 
the whole course of the labor, the 
lowest in the pelvis. In this, as 
in the third position, a certain 
number of cases terminate with 
the forehead under the pubis, the 
mechanism, in each case, being pre- 
cisely similar, the occiput usually 
passing over the fourchette, where- 
upon the forehead, nose, and chin, 
sweep successively, backwards and 
downwards, from behind the pubic 
symphysis. The position of the 
foetal head in reference to the out- 
let of the pelvis is shown in the 
engraving. If we admit the pos- 
sibility of conversion of a third 
position into a face case by rota- 
tion on the transverse axis of the 
head, Ave must also admit it in the case of the fourth position. And 
it is worth noticing that such a rotation would directly, and without 
further change, convert the position which we are now speaking of 
into that position of the face which is most frequent in its occurrence. 
In all cases in which the forehead is born forwards, the ordinary pro- 




Fourth cranial position at the outlet. 



XVIII.] FOURTH CRANIAL POSITION. 309 

cess of moulding is reversed, and the head presents a very remarkable 
appearance, owing to the flattening of the occipital, and bulging of the 
frontal regions. 

The comparative difficulty which arises from the situation of the 
rectum constitutes, therefore, as it would seem, the only practical dis- 
tinction between third and fourth positions. All observers seem to 
have agreed in this, — that, in the fourth, the rotation takes place as a 
rule, and probably, on account of this very difficulty, on a higher level 
as regards the pelvis ; and that, if it descends to the floor of the pelvis 
with the forehead still directed towards the right obturator foramen, 
the chances of rotation at this more advanced stage are less than in the 
third. Rotation, at an early stage of labor, before it is yet practicable 
to ascertain the actual position of the head with anything like certainty, 
is probably of much more frequent occurrence than we have any idea 
of. Few things are more familiar to the experienced accoucheur than 
a rotatory or rolling movement of the head, which he observes either 
during a pain or an interval, while it is still high in the pelvis. This 
is due partly to uterine action, and partly to the movements of the 
foetus, and we have no doubt that, by this means, many unnatural and 
faulty positions are rectified even after labor has commenced; and we 
are further entitled to assume that in this way many ocoipito-posterior 
positions are rectified at such a stage that their detection is rendered 
impossible. It should always be remembered that the dorso- or occipito- 
anterior position of the child is the natural one, and that according to 
which the irregular oval which it forms is most conveniently disposed. 

Recognizing, as we now do, the natural termination of third and 
fourth cases as second and first respectively, -a very important practical 
point arises, which may perhaps be most conveniently discussed at this 
place. This is the possibility of rectification by artificial means of 
occipito-posterior positions, which are about to terminate, or threaten 
to terminate, with the forehead towards the pubis. No possible doubt 
can exist as to the fact that the position of the head may be, and often 
has been changed by the operations of the accoucheur. In confirma- 
tion of this assertion, we have the evidence of the most eminent obstet- 
ricians. More than a century ago, Smellie, after having repeatedly 
but in vain attempted to drag the head through in a case of this kind, 
bethought him of trying to turn the face backwards into the hollow of 
the sacrum. Success attended his first attempt — a result which " gave 
him great joy," and opened his eyes to a new field of improvement "in 
the method of using the forceps in this position." Clarke, Burns, and 
others, stated that rectification could be brought about in many cases 
by the use of the finger alone. Among accoucheurs of our own day, 
Drs. Murphy and West have emphatically expressed their views in favor 
of the feasibility of this proceeding. 

As regards the period of labor at which rectification may be effected, 
we find that many writers assume, or at least imply, that the operation 
may be performed at any stage. The fact is, however, that the head 
cannot in ordinary circumstances be rotated until it has reached that 
stage of the labor where nature as a rule spontaneously induces the 
rotation, so that it will often be a matter of difficulty to say what share 



310 MECHANISM OF LABOR. [CHAP. 

in the movement we are to award to nature and what we may claim 
as the result of oar operative interference. The conclusion with refer- 
ence to the subject at which we have arrived is that we may succeed in 
amending the position of the head in two classes of cases. In the first 
of these, the head is free at the brim, or at least has not as yet encoun- 
tered any serious pelvic resistance ; and here rotation may be effected 
by the forceps in a manner which will be more particularly alluded to 
when we come to speak of the uses of that instrument. In the second 
class of cases referred to, the head has reached the floor of the pelvis, 
where we have natural rotatory forces operating in our aid ; but no 
attempt, while the head is in a situation intermediate between these 
two, is likely to be attended with success. 

The forceps is quite inapplicable to the class of cases last mentioned, 
for reasons which are obvious. The surest and safest guidance is to 
be found in a careful study of the mechanism by which nature at 
this stage effects the rotation. And if we do so, it will soon become 
apparent that it is only by imitating or assisting nature that we can 
hope for success. If we attempt simple rotation, the ischial spines 
interpose a barrier which it is impossible to surmount; but, if we, on 
the other hand, take nature for our guide, and assist her in the direc- 
tion which she indicates, we must employ our whole efforts in promoting 
the preliminary flexion of the head, which has been fully explained in 
the description of the third position. With this in view, then, we 
should press the forehead upwards, in the direction of the ilio-pectineal 
eminence, on the side in which it lies. This is done most effectively by 
bringing two fingers to bear upon it and pressing in the direction 
indicated during a pain. This, in the first instance, will probably have 
little effect in displacing the forehead, but if we can only succeed in 
preventing its further descent, we thus transfer in some measure the 
propulsive force to the occiput, and in a greater or less degree encour- 
age the essential movement of flexion. After a time, the effect of this 
will probably become manifest in a recession of the frontal pole of the 
long diameter. But, should the effort fail, we may, as Dr. West sug- 
gests, attempt to pull down the occiput by means of the instrument 
called the vectis, while continuing the pressure with the fingers as 
before. By one or other method, or by a combination of both, we may 
often succeed in effecting the natural flexion of the head, until the fore- 
head is high enough to pass above one ischial spine and the occiput low 
enough to pass beneath the other, when nature herself will effect the 
actual rotation, and may be left to complete the labor without any 
further interference. Madame Boivin seems to have entertained the 
belief that, in the third position, something may be gained by emptying 
the rectum so as to facilitate rotation into the second ; and that, as 
regards the fourth, a distended rectum is rather an advantage than 
otherwise, inasmuch as it would tend to prevent the movement of the 
occiput into the hollow of the sacrum, and so indirectly encourage the 
rotation into the first position, which we desire to promote. 

[Sixth Position. — In this position the occiput is directed to the 
sacrum and the forehead to the pubis. It is very rare. Dewees met 
with three, and Meigs with two cases. In most instances it is sponta- 



XVIII.] OCCIPITO-POSTERIOR POSITIONS. 311 

neously converted into a fourth or fifth position, owing to the convexity 
of the occiput, which constantly tends to throw the head to the right 
or left side of the projection formed by the junction of the sacrum and 
lumbar vertebras. When the position persists, the eervico-bregmatic 
diameter of the head is in the conjugate of the superior strait, and the 
biparietal in the transverse. Flexion being completed, the head 
descends without rotation until the occiput is delivered, after which 
backward extension of the head brings the forehead and face into the 
world as in fourth and fifth positions which terminate in posterior 
rotation. 

Either shoulder may come under the arch of the pubis, after which 
the mechanism of delivery is similar to that of the third position. In 
the former case, however, the occiput rotates forwards, and in the latter 
backwards, to effect this. — P.] 

While the four positions which have now been described are all 
which we think it necessary to specify in detail, there can be little 
doubt that, under exceptional circumstances, others may be met with. 
The accidental position, for example, of the head in the conjugate or 
transverse diameters of the brim has, in the opinion of many approved 
authorities, warranted them in adding four more, making eight posi- 
tions in all. We apprehend, however, that the mechanism, in such 
rare instances as may be met with of conjugate or transverse as primary 
positions, does not call for any special description, and that to admit 
them would be unnecessarily to complicate a subject already beset with 
sufficient difficulties. Both of the positions indicated would, in a normal 
pelvis, inevitably be resolved into one or other of those which have 
been described, and would thus terminate according to the laws which 
we have attempted to elucidate; while, if they were the result of ab- 
normal disproportion of the parts, they would come under the influence 
of special laws, which it is no part of our object at present to explain. 
We take no notice, it will be observed, of premature birth or putridity 
of the foetus, in which the child may pass in any diameter; but even 
here the tendency is to follow the natural course. 

We have now to consider the subject of the Comparative Frequency 
of the cranial positions. It may be considered that this ought to have 
been referred to at a somewhat earlier stage. We have, however, pur- 
posely postponed it until now, as considerations arise, in reference to 
points not yet fully determined, which can only be understood by those 
who are in possession of the facts which have been detailed in this and 
the preceding chapter. It is to be regretted that no inconsiderable dif- 
ferences of opinion, on many of the points referred to, have arisen in 
consequence of the views of Naegele having been implicitly received, 
while yet they have obviously lacked confirmation. 

From the time of Smellie, the first position has been universally 
admitted as that which is by far the most frequent. Until the publi- 
cation of Naegele's celebrated essay, there was a similar unanimity 
among obstetricians as to the second position being next in point of 
frequency to, and in all respects the converse of the first ; but the effect 
of his researches upon the minds of all modern practitioners has been 
to modify greatly, and in most cases entirely to overthrow, the conclu- 



312 



MECHANISM OF LABOR. 



[CHAP. 



sions of his predecessors on this point. In order to avoid a mass of 
statistical details, we shall only attempt here to compare the conclusions 
of Naegele, and of those who agree with him, with the results attained 
by some modern observers who differ from him more or less widely. 
It is beyond doubt that his original doctrines are, to the present day, 
more fully believed in this country than in France, America, or even 
in Germany ; and this is obviously due to the fact that many of our 
most eminent accoucheurs have taught and still teach these doctrines, 
while some believe that they have confirmed their accuracy by subse- 
quent research. All this is shown in the following tabular analysis; 
but it is therein further made .evident that there are many men of un- 
doubted talent and experience who decline to accept the evidence even 
of Naegele as of greater weight than that of their own senses. The 
following table shows the percentage of each of the four cranial positions, 
as deduced from the published statistics of the observers quoted : 





First 
Position. 


Second 
Position. 


Third 
Position. 


Fourth 
Position. 


Not 
Classified. 


Naegele, 

Naegele, the younger, 
Simpson and Barry, . 

Dubois, 

Murphy, 

Swayne, 


70. 

64.64 

76.45 

70.83 

63.23 

86.36 


' '.29 
2.87 

10.18 
9.79 


29. 
32.88 
22.68 
25.60 
16.18 
1.04 


' '.58 

.62 
4.42 

2.8 


1. 

2.47 



By means of this tabular arrangement, we see at a glance the extent 
to which, apparently, one observer differs from another, but we must 
look a little closer at the figures to discover their true import, In the 
first place, we may observe that the two Naegeles regarded the second 
and fourth positions as so exceptional that they did not include them at 
all in their system of classification, contenting themselves with the as- 
sertion that, when present, there were either some special circumstances 
which induced the irregularity, or that the observations w T ere not made 
sufficiently early in the labor. The elder Naegele, indeed, says that, to 
positions of the third kind, those of the face come next in point of fre- 
quency, while the second is classed by him with the conjugate variety as 
rarest of all. The younger Naegele, again, who, while he enters into 
statistical details much more deeply, repeats and corroborates his father's 
doctrines, lays himself open in more than one place to criticism, in respect 
of the manner in which he disposes of his statistics to suit his own views. 
He states, for example, that his conclusions are based on 3795 cases of 
cranial presentation, but instead of placing these fairly under the four 
heads which constituted essentially the classification of the German 
school, he coolly says : "After deducting 94 cases, in which the original 
position of the head could not be made out on account of various cir- 
cumstances, we have 3701 carefully observed cases of cranial presenta- 
tion." Now, these 94 cases form nearly two and a half per cent, of 
the whole, and if divided, as we cannot doubt they ought to have been, 
between the positions numbered second and fourth, would have brought 
the statistics of Naegele very near to those of Dubois, whose observations 



XVIII.] STATISTICS OF CRANIAL POSITIONS. 313 

accord perhaps as closely as those of any other with the prevailing ideas 
of the present day. 

The statistics of Simpson and Barry confirm the conclusions of 
Naegele more closely than any others ; but it will be observed that a 
certain percentage of second and fourth presentations is admitted, which 
becomes more marked in the figures of Dubois. 

The conclusions arrived at by the two observers whose names are 
placed last upon the list, indicate a startling discrepancy witli the 
results given above, and are of themselves sufficient to show that the 
doctrines of Naegele are by no means definitely settled. Dr. Murphy's 
conclusions are the result of a careful personal observation, in the 
Dublin Lying-in Hospital, of sixty-eight cases of cranial presentation, 
in which he found the second position to occur as frequently as the 
third. His conclusions may at first seem to be less satisfactory than if 
they had been based upon a larger number of observations ; but, at the 
same time, we must admit that the results obtained by so able and ex- 
perienced an accoucheur as Dr. Murphy, should be held as more likely to 
be correct than when the observations on which statistics are founded 
are intrusted in a great measure to others. The experience of Dr. 
Swayne shows a larger number of cases of first position than any other 
observer, and in other respects his deductions are still more strikingly 
opposed to the idea generally received. Reverting to the opinion held 
before Naegele, he believes that in point of frequency the second comes 
after the first, and that the fourth is more frequent than the third, an 
opinion in which he is supported by Professor Millar of Louisville. In 
the table above given we have avoided extremes, or we could have given 
statistics which have been offered in proof of assertions which are, as 
regards the views of Naegele, more contradictory still. 

In attempting to reconcile statements so conflicting, we cannot fail 
to become convinced of the fact that, even in the most experienced 
hands, it is no easy matter to determine the position of the head in 
the early stage of labor. It is not to be conceived that all the ob- 
servers above quoted can be right. It is equally clear that nature 
must have some law, according to which the head of the child enters 
and passes through the pelvis of the mother. But is it in our power to" 
determine what is this law of nature, and in what this or that observer 
has erred? Can we so reduce the law to statistical results, as to place 
the matter forever on the basis of irrefragable evidence ? He would 
be a bold man who, in the present state of the art, would venture to 
answer these queries in the affirmative. For our part, we are con- 
vinced that there is ample room for renewed observation and research ; 
but unless a man can bring to bear upon the subject a mind un warped 
by prejudice or preconceived ideas, his testimony will be of little avail. 
Take by way of example of this, the second position. Who has not 
been summoned again and again, to the bedside of a woman in labor, 
to find the head in the lower third of the pelvis, and in the position 
in question ? In such a case the disciple of Naegele would probably 
record in his note-book, a A case of third position, in which rotation 
had occurred before my arrival." He is driven to this conclusion, if 
he adopts Naegele's theory, but yet, as regards the individual case, the 



314 MECHANISM OF LABOR. [CHAP. 

evidence is Naegele's and not his. Or, again, if quite early in labor he 
finds the head undoubtedly in the second position, he classifies it las 
irregular, and assumes the presence of some of the "various circum- 
stances" in which only, says Naegele, this position can occur. To.be 
candid, however, we must admit of the possibility of a mistake which 
is the converse of this, and which would be committed by him who 
should rank every case as second, without any reference to the stage at 
which the first examination is made. It must, we think, be manifest, 
that correct conclusions on this subject can only be based upon a large 
number of observations, in which the position of the head is ascer- 
tained in every case at the beginning of the labor, or before it expe- 
riences any pelvic resistance further than that which is due to gravity. 

Granting that the first position is by far the most frequent, occurring, 
as it does, in nearly 70 per cent, of all cranial presentations ; and, 
granting further, as we do, that Naegele's discovery — that the third is, 
as a primary position, next to the first in point of frequency — is correct, 
we are persuaded that both second and fourth cases occur more fre- 
quently than is generally supposed, — certainly much more frequently 
than Naegele would have us believe. We are inclined to think that, 
by striking an average between the percentage yielded by the statistics 
of Dubois and Murphy respectively, we should come very near the 
truth. 

The proportion thus deduced stands nearly as follows : 

First Position. Second Position. Third Position. Fourth Position. 

67 10 20 3 

The second cranial position is, in all respects, both as regards pelvis 
and cranium, the exact converse of the first, and it is difficult to account 
for its comparative infrequency on any other ground than the presence 
of the rectum on the left side. It is somewhat strange that Naegele 
should reject this theory as improbable, as it is very obviously in favor 
of his argument that all cases, almost without exception, lie originally 
in the right oblique diameter ; but perhaps we should, instead of being 
surprised at this, take it as evidence of his impartiality. Whether the 
rectum may, or may not, have an influence in determining the original 
position, it is clear that it bears practically on the progress of labor, 
especially if distended. But, even should it be empty, it is conceivable 
that the thickness of the coats of the bowel may tend to make a tight 
fit tighter. 

The proportion of occipito-posterior positions which end with the 
face to the pubis is, for obvious reasons, very difficult to determine. It 
is not to be wondered at, perhaps, that great difference of opinion exists 
as to the proportion of cases which perform the usual rotation back- 
wards; but it is a little astonishing that the actual number of cases 
ending with the face forwards should be overlooked or misunderstood. 
Naegele did not believe in the face-to-pubis termination of such cases, 
except under peculiar circumstances, — such as a small head or a large 
pelvis, — but there are probably few accoucheurs of large experience, 
who take the trouble to observe what passes under their eyes, but have 
met with such cases, there being no peculiar circumstances whatever to 



XVIII.] FACE PRESENTATIONS. 315 

account for them. Drs. Simpson and Barry came to the conclusion 
that, in the third position, spontaneous rotation occurred in 96 per 
cent.; while, still more recently, Dr. West found that in 481 cases 
observed by himself, 15 third cases were born, or were about to be born, 
with the forehead in advance ; but these included, it must be remem- 
bered, cases in which he rectified artificially the position of the head, 
on the assumption that, had he not interfered, they would certainly 
have terminated with the face to the pubis. In regard to rotation in 
the fourth position, the number of cases observed is so small that no 
reliable data are to be found ; but the impression generally prevails, 
that spontaneous rotation, in such cases, is effected with greater diffi- 
culty, and the tendency to fronto-anterior termination is thus propor- 
tionally increased. 

■Face Presentations. — The only other varieties of possible presenta- 
tion of the cephalic extremity of the child which it is necessary hereto 
consider are the various positions of the Face. These occur about once 
in 230 cases. The causes which lead to this unusual occurrence are 
not well understood, but the initiatory movement which results in the 
position can only be, as is obvious, a movement of extension which, at 
an early stage of labor, or prior to its occurrence, is substituted for the 
usual movement of flexion occurring during labor in the ordinary posi- 
tions of the cephalic extremity. In other words, and to take the most 
simple view of the matter, cranial are converted into facial positions by 
a simple movement of the head on its transverse axis. As, in this and 
other respects, there is a very close analogy between the mechanism of 
face and vertex presentations, we introduce the subject of the former at 
this place from a conviction that it will be much more easily under- 
stood if studied along with the ordinary cranial positions. 

In pursuing the analogy which exists between the face and the vertex, 
we note, in the first place, that the " obstetrical " differs from the 
" anatomical " face in including the forehead. The long diameter of 
the face, therefore, which extends from the centre of the forehead 
between the frontal protuberances to the tip of the chin, corresponds 
to the occipitofrontal diameter; and, in like manner, the transverse 
diameter, from one malar bone to the other, corresponds to the bi- 
parietal measurement of the cranium. We observe, further, in looking 
closely at the facial oval, that the pointed chin represents the occiput, 
while the forehead is, in each position, the broad end of the long 
diameter. A premature and exaggerated movement of extension of 
the head having thus, as we conjecture, converted a cranial into a facial 
position, we find that in its descent and birth, it follows the same me- 
chanical laws as those which govern the vertex. Movements are thus 
executed, which in every stage correspond to those already described, 
with this important distinction, that the relation which they bear to the 
trunk of the child is in some respects reversed. This will become 
apparent as we proceed. The face, like the head, and for similar 
reasons, descends into the pelvis with its long diameter in one or other 
of the oblique diameters of the brim. There are thus four positions in 
which we may find the face, according as the presentation may have 
been originally a cranial position of the corresponding number. It 



316 . MECHANISM OF LABOR. [CHAP. 

will be observed, however, as a most important distinction, that the 
numbers of the Mento- Anterior variety do not correspond to the oc- 
cipitoanterior of the cranium. Each presentation as numbered is, we 
repeat, supposed to be produced from the corresponding cranial position, 
by a simple movement on its transverse axis. 



M ENTO-POSTERIOR, 



Mento- Anterior, 



v , D ... f Face in Ri<rbt Oblique Diameter 

Jb irst Position, { r , ,=?. -, H 

' I ioreliead lorwards. 



Second Position, \ F " ce ] n L * ft 0bl ^ ue Di « meter 

' ( ioreliead forwards. 

rm • 7 r> -j- f Face in Ri<rbt Oblique Diameter 

iliird Position, { .. , . P , \ 

' ( Ioreliead backwards. 

xt, , 7 D ... f Face in Left Oblique Diameter 

Jbourth Position, < ,. , -, T , M . 
( ioreliead backwards. 



The chin, in all these positions, being looked upon as the mechanical 
equivalent of the occiput, it follows that the Mento-Anterior varieties 
in which the front of the child is turned forwards, are the natural 
terminations of all face cases. This, indeed, is the case in a much 
stricter sense than in presentations of the cranium, for reasons which 
will appear presently. We shall, therefore, in the first instance, con- 
sider these two positions ; and, as the fourth is the one which occurs 
most frequently, we shall commence with it. 

Fourth Position of the Face. — Although it is not the usual course in 
these cases, we are entitled to assume it as possible that this position 
may be produced from the fourth of the cranium by a movement on its 
transverse axis, which brings the chin towards the right ilio-pectineal 
eminence, the head being extended so as to bend the occiput towards 
the nape of the neck. The long diameter, indicated by the direction 
of the nose, lies in the left oblique diameter, with the forehead towards 
the left sacro-iliac synchondrosis. The finger, on an examination, first 
reaches the right malar bone, which is the part deepest in the pelvis, 
and the presentation itself is made out by feeling the nose, mouth, and 
other features, care being taken not to injure these delicate parts by 
rough and careless manipulation. The long diameter descends ob- 
liquely, with the chin in advance, in proportion to the degree of resist- 
ance. The caput succedaneum will be found to involve the right malar 
bone, the right angle of the mouth, and the parts immediately adjoin- 
ing. When the face reaches the floor of the pelvis, the chin is directed 
by the right ischial spine downwards and forwards, along the corre- 
sponding anterior ischial plane, while the forehead glides along the left 
sacro-sciatic ligaments towards the hollow of the sacrum, precisely as 
in the second cranial position. Having reached the perineum, and 
probably still retaining a certain degree of pelvic obliquity, the chin 
now moves forward under the pubic arch. The perineum becomes 
distended, and the chin having moved sufficiently forwards to release 
the mental pole of the occipito-mental diameter, the emergence of the 
head takes place by a movement of flexion, the face being born forwards 
and upwards as the nose, forehead, vertex and occiput successively 
sweep over the perineum — all of which takes place with no greater 
difficulty than in an ordinary cranial position. The shoulders having 
descended in the right oblique diameter, the right shoulder is lowest 



XVIII.] VARIOUS FACIAL POSITIONS. 317 

and in front. This part, therefore, is, in its turn, rotated from left to 
right, along the anterior plane of the left ischium, while the left shoulder 
retreats into the hollow of the sacrum ; and in this position they pass, 
as has already been fully described, under cranial positions, a corre- 
sponding movement of restitution being at the same time performed 
by the head. The trunk and breech follow as under ordinary circum- 
stances. 

Third Facial Position. — In this the mechanism is precisely similar 
to that which has just been detailed. The face, however, lies in the 
right oblique diameter, the forehead being to the right sacro-iliac syn- 
chondrosis, and the chin in the direction of the left ilio-pectineal emi- 
nence. The left side of the face is lowest in the pelvis, and it is on 
this that the caput succedaneum forms. The chin descends, and rota- 
tion takes place as in the former case, only in the contrary direction, 
the details of the process being in every respect similar. 

First Facial Position. — In this, and in the remaining position, the 
prominence of the chin is turned backwards. Following the method 
which we have adopted with the view of maintaining as closely as pos- 
sible the analogy subsisting between facial and cranial cases, we ob- 
serve that the Mento-Posterior positions correspond closely with the 
fourth and third cranial. As in the mento-anterior variety, we may 
accept the chin as representing the occiput. The First Facial Position 
is produced from the first of the head, by a movement of extension. 
Its long diameter corresponds, therefore, to the right oblique diameter 
of the pelvis, the chin being directed to the right sacro-iliac synchon- 
drosis, and the centre of the forehead towards the left ilio-pectineal 
eminence. The chin thus occupies the position where the occiput lies 
in a third cranial position. The part which is lowest in the pelvis, 
and which the finger feels from the vagina through the anterior walls 
of the uterus, is the right malar bone. If the os is sufficiently dilated, 
we may feel through it the bridge of the nose. Carrying the finger, in 
reference to the position which the woman occupies, downwards and 
forwards, we may reach the forehead, the frontal suture indicating the 
path from the bridge of the nose to the anterior fontanelle ; w r hjle, by 
passing it in the opposite direction, upwards and backwards, we may feel 
the ridge of the nose, and the mouth, where the alveolar ridge may be 
distinguished, and ultimately reach the chin. Should the resistance of 
the os, at this stage, be such as to cause the development of a caput 
succedaneum, it will be found to occupy the upper half of the right 
side of the face, and will generally, to some extent, involve the eye. 

With regard to this position, the same observation may be made as 
in regard to the third of the cranium, — that it may terminate in two 
ways : with the chin towards the hollow of the sacrum ; or, by a rota- 
tion forwards, which, by bringing the chin upon the right anterior 
ischial plane, converts it into the fourth position, already fully described. 
Although Smellie, and many writers of merit since him, describe cases 
of facial presentation in which the chin passes into the hollow of the 
sacrum, and is born over the perineum, it is only with difficulty that 
we can admit — for reasons which will be detailed afterwards — a bare 
possibility of such a termination of labor by the natural efforts. The 



318 



MECHANISM OF LABOR. 



[CHAP. 



head, therefore, adopts a course very similar to what obtains in third 
cases of the cranium. As in the one case the occiput, so in the other 
the chin descends, prior to rotation, somewhat in advance of the fore- 
head. The fronto-mental diameter being, however, more than an inch 
less than the occipitofrontal, the same degree of obliquity is not neces- 
sary as an essential preliminary to rotation. And it is fortunate that 
it is so, for the head is already so strongly extended that a further 
extension seems all but impossible. In the course of the rotation, the 
chin comes in front of the right ischial spine, while the forehead moves 
upwards and backwards towards the left sacro-iliac synchondrosis, and 
the case is thus converted into what we have already described as the 
fourth position of the face. The rotation, therefore, which converts 

Fig. 115. 




Diagram showing successive stages of rotation and delivery in the first facial position. 



the first facial into the fourth is, if we read "chin" for "occiput," 
essentially the same as occurs when the third of the vertex rotates into 
the second. Less obliquity of the long diameter of the face being re- 
quired, the rotation of the face takes place with greater ease, which is 
another reason why we should look upon this as the only natural termi- 
nation of that position of the face which is the result primarily of a 
movement of extension of a head occupying the first position of the 
vertex. The accompanying diagram (Fig. 115) shows the various 
stages alluded to. 

Second Facial Position. — In this, which is the converse of the first, 
the face is in the left oblique diameter, with" the chin to the left sacro- 
iliac synchondrosis, and the forehead to the right ilio-pectineal eminence. 



XVIII.] VARIOUS FACIAL POSITIONS. 319 

The chin, therefore, lies in the direction which the occiput occupies in 
the fourth cranial position, and the part which is lowest in the pelvis is 
the left malar bone. The normal and almost invariable termination of 
such a case is a rotation analogous to what is observed in the fourth 
position of the vertex. The chin in this way becomes applied to the 
left anterior ischial plane, along which it glides as in what we have 
described as the third facial position, so as to bring it under the arch 
of the pubis, where the labor is terminated in the usual way. 

The relative frequency in the occurrence of the various positions of 
the face might not unnaturally admit of considerable difference of 
opinion. For, if the ordinary positions of the cranium, which are so 
familiar to us, still admit of doubt in this respect, it is not to be 
wondered at, that doubt may still attach to this rare and, as some term 
it, faulty presentation. If we are correct in assuming, what is very 
generally admitted, that presentations of the face are the result, in the 
corresponding positions of the vertex, of a simple movement of the 
head on its transverse axis, the numbers which we have attached to the 
various facial positions have a special significance in indicating the 
original position of the head. But there the numerical correspondence 
ceases. For, the more closely we look at the relation which the one 
presentation bears to the other, the more obvious does it become that 
the chin is mechanically the analogue of the occiput, and that, there- 
fore, the anterior surface of the foetus is turned forwards in all face 
cases which are to be regarded as normal. In cranial positions on the 
contrary, the back is, as a rule, turned forwards. This, while it so 
far destroys the analogy between the two classes of cases, establishes 
between them more important practical points of resemblance ; for our 
object is, in any assistance which we may consider ourselves justi- 
fied in offering, to bring the occiput forward under the pubic arch in 
cranial positions, so in these also we may use what means we can, with 
the view of aiding in a similar way the descent and precedence of the 
chin. The aphorism of Roederer might, in fact, if we substitute the 
word "mentum" for " occiput 7 ' be admitted as the leading principle 
upon which nature conducts all such labors. " Indifferens est quisnam 
sit capitis positio, modo pars conica atque arctissima, mentum nempe, 
descendat." 

In point of relative frequency, therefore, we must speak with some 
caution. No doubt can exist with reference to the fact that the third 
and fourth, or men to-anterior, positions are the natural terminations of 
all face cases. In what proportion of these, third and fourth positions 
of the cranium have become directly transformed, as we have conjec- 
tured, into the corresponding facial positions, it is, and probably from 
the rarity of the cases always will be, impossible to determine. That 
such a transformation is possible, no one can deny ; that it is proba- 
ble, we will venture to assert. And, moreover, should it so occur, the 
change of a fronto-anterior position of the cranium into a mento-anterior 
of the face must be looked upon as a much more favorable termination 
of a labor, than the tedious process already described which, in a cer- 
tain proportion of such cases, brings the occiput over the fourchette 
before the face can pass from under the pubis. It is on this ground, 



320 MECHANISM OF LABOR. [CHAP. 

indeed, that we have considered ourselves justified in taking note of 
these as distinct positions, and not merely as stages in the course of the 
other two. 

If we take into consideration, moreover, the enormous preponder- 
ance of cases in which the cranium or vertex presents with the forehead 
backwards, we readily admit that it is much more than probable that 
the men to-posterior positions are, in the earlier stages of labor, the 
usual positions of the face. The fact again that the first position of the 
cranium occurs in nearly 70 per cent, of the four varieties of these cases, 
suffices to account, on the principle of rotation, for the preponderance at 
the moment of delivery of fourth over third facial positions. But the 
fact recorded by Naegele, that the preponderance alluded to amounts 
only to twenty-two fourth, as against seventeen third, facial positions 
can only be accepted as confirmatory of his statements as to the fre- 
quency of the various vertex presentations, by supposing that the third 
position of the cranium is, as we have assumed, not unfrequently con- 
verted by simple extension into the corresponding position of the face. 
Otherwise, the disproportion would be much greater ■ between the two 
mento-anterior terminations than he assumes. 

That mento-posterior positions may terminate as such in a large 
pelvis, or in cases of premature delivery, we may admit as possible. 
But, if we consider carefully what this termination implies, in the 
case of an ordinary pelvis and a fully developed head, we find it im- 
possible to conceive a degree of extension which would involve such 
compression and moulding of the head, as would bring the occiput 
into relation with the dorsal vertebra? before the chin could reach the 
posterior commissure of the vagina. We believe, therefore, that the 
cases upon which the assertions of Smellie and others are founded 
must have been of the exceptional nature above referred to. And, 
if such cases do occur, the mechanism at the moment of birth of the 
head must be the arrest of the chin at the fourchette, and a movement 
of flexion which, while relieving the head from its constrained position, 
brings the mouth, nose, forehead, and vertex successively in a back- 
ward direction from beneath the pubic arch. 

All presentations of the face were at one time supposed to be ab- 
normal and dangerous. This belief gave rise to different methods of 
operative interference, which were devised with the view of rectifying 
the presentation. Of these, the operation of turning found special 
favor in the eyes of the older accoucheurs, who did not scruple, as a 
matter of routine, to introduce the hand, and turn in all cases in which 
the presentation was recognized at a period sufficiently early in the 
labor. Till the beginning of the present century, indeed, this was the 
mode of procedure which received the sanction of the most eminent 
authorities. The attention which about this time was directed to the 
subject of scientific obstetrics soon showed how erroneous was this view, 
and how greatly increased was the risk both to the mother and child 
by the operation of turning. But the idea of necessary interference of 
some kind had got too firm a hold of the professional mind to be at 
once dispelled, and we therefore find substitutes for the discarded oper- 
ation sanctioned by the authority of some great names. We find, for 



XVIII.] MENTO-POSTERIOR POSITIONS. 321 

example, that it was recommended by Dr. J. Clarke, to allow the face 
to descend into the cavity of the pelvis, and then by steady pressure 
exercised upon the presenting malar bone during a pain, to push the 
face into the hollow of the sacrum, and allow the occiput to descend. 
That Dr. Clarke may have succeeded, as he says, in such cases, we 
must not doubt; but we confess to great skepticism as to the feasibility 
of such a proceeding under ordinary circumstances, and we have little 
doubt, if we did succeed, the risk to the child would be rather in- 
creased than lessened. 

Until it had been demonstrated by Naegele, accoucheurs were quite 
ignorant of the rotation which occurs in the great majority of face 
cases, whereby, in mento-posterior cases, the" chin spontaneously comes 
forward under the pubis. It was therefore a totally erroneous impres- 
sion of the nature of these labors which led Baudelocque to suggest, 
and so many of his followers to adopt, an operation which is scarcely 
less objectionable than turning. In recommending the operation re- 
ferred to, he directs us to pass the finger through the os, and along the 
anterior wall of the uterus over the forehead, and then, rupturing the 
membranes, attempt to drag down the occiput. This he naturally 
conceived to be better than to leave the case to nature, believing as he 
did that all mento-posterior cases could only terminate as such. These 
and all other similar modes of procedure were at once thrown aside 
when the fundamental errors from which they sprang were removed 
by the industry and genius of Naegele. 

In face presentations, as they occur in actual practice, we believe the 
safest rule for our guidance is to avoid interference as far as possible. 
In occipi to-posterior positions of the cranium, we have recommended 
interference in such cases only as threaten to terminate with the fore- 
head in advance, and the same rule should guide us in our manage- 
ment of the face. When the chin is originally forwards, or has already 
rotated, no interference whatever is required. It is usually recom- 
mended, however, in the mento-posterior positions, to aid the rotation, 
either by hooking the finger into the mouth, and making cautious 
traction in the proper direction, or by some other mode of manual in- 
terference, with the view of bringing the chin towards the pubic arch, 
as the face is about to emerge from the pelvis. It is doubtful, how- 
ever, whether such interference should be sanctioned as the proper 
routine procedure. So many delicate points have here to be attended 
to — the direction of the pressure, the time for operation, and the like 
— that w T e incline to the belief that nature should, in the great majority 
of instances, be trusted to. For, if the practitioner of average expe- 
rience can have but a few cases to observe in the course of a lifetime, 
it is scarcely to be expected that he can attain such special skill as to 
act with unfailing precision. While, however, we can bear personal 
testimony to the possibility of operative rectification of these positions, 
we would, in ordinary cases of this nature, certainly prefer to watch 
carefully the process which nature is adopting, and act only in such 
instances as she may seem to be calling for assistance. 

It may be necessary, in facial as well as in cranial positions, to give 

21 



322 MECHANISM OF LABOR. [CHAP. 

assistance by manual or operative interference in cases in which delivery 
is delayed, although the parts are normally situated. Such aid as, 
under the circumstances, it may seem necessary to afford, is to be em- 
ployed in each case on the same principles. The only points which 
are here to be remembered as distinctive, arise from the facts — that in 
facial position, the vessels of the neck are, in consequence of the pecu- 
liar position, subjected to very unusual pressure, and that the adjacent 
maternal organs are also likely to be compressed by the manner in 
which the child's head is doubled back. Both of these conditions 
should lead us, therefore, to watch the progress of such a case some- 
what more strictly than usual, in order, if possible, to detect the 
earliest indications of abnormal obstruction to delivery, and so soon 
as this may arise, to relieve it without delay. The forceps, for exam- 
ple, may be employed in such cases, at a period somew 7 hat earlier than 
is considered necessary in cranial positions, in proportion exactly to 
the imminence of the danger which we apprehend. Should it, how- 
ever, occur that the head descends to the floor of the pelvis, and yet 
no effort is made in the way of rotation, it will be proper to aid the 
movement in question, having first carefully ascertained the position 
of the face, and calculated the direction in which our efforts should be 
applied. Persistent mento-posterior cases may possibly, as has already 
been said, terminate as such, if the child be premature or putrid, or 
the pelvis of unusual capacity; but if, owing to the disproportion of 
parts, or some other special cause, rotation should not be effected, the 
inevitable result is such obstruction as may be called insurmountable; 
and in these instances the crotchet and the perforator may be required 
before the relief of the woman is effected. 

[If rotation cannot be effected by the measures recommended by the 
author, it is doubtful whether the obstruction should "be called insur- 
mountable," and the perforator resorted to without a trial of another 
measure. In November, 1873, the editor read a paper before the 
Obstetrical Society of Philadelphia, on "The Use of the Hand to cor- 
rect unfavorable Presentations and Positions of the Head during Labor." 
In this was related a case of face presentation, with the chin behind and 
to the right side, seen in consultation with Dr. Elliot Richardson. 
The face was almost at the inferior strait. All attempts to flex the 
head, to rotate the chin in front, or to deliver by traction with the 
forceps failed. The woman was completely exhausted, and there seemed 
to be no alternative but to perform craniotomy. Before resorting to 
this, however, I passed my whole hand into the pelvis, and placed the 
thumb over the brow and the fingers over the superior maxillary bone, 
" and pushing forcibly upwards, the head was easily raised above the 
brim of the pelvis. It was then flexed without any difficulty, and a 
mento-posterior of the face was converted into an occipitoanterior of 
the vertex." Wallace's forceps were promptly applied, and a few 
minutes later we had the satisfaction of delivering a living child. 

To successfully perform this manipulation the woman should be 
completely under the influence of an anaesthetic. When the patient 
is thoroughly relaxed by ether, " it is very surprising what can be 



XVIII.] MENTO-POSTERIOR POSITIONS. 323 

done by forcibly pushing the head upwards. Not only does the child 
ascend, but if the lower segment of the uterus has been carried with 
the head into the cavity of the pelvis, it may be lifted with its contents 
above the pelvic brim, where the latter become movable and easily 
manipulated. Both in the pregnant and unimpregnated woman, the 
degree of stretching and movement of which the generative organs are 
capable when the patient is completely anaesthetized, appears very 
remarkable to one who has never employed this important agent in 
such cases.' 7 

For further information in regard to this subject, the reader is referred 
to the paper alluded to, which was published in the American Journal 
of Obstetrics for May, 1875. It is not to be supposed that the measure 
here described will always prove successful, but the happy result of the 
case alluded to, warrants the hope that it will sometimes obviate the 
necessity of resorting to the perforator, the most horrible of all obstetric 
instruments. — P.] 

Although but four positions are above described, it may be said of 
face, as of cranial positions, that there is no possible diameter of the 
brim which may not be occupied, in some case or other, by the long 
diameter of the face. And, in regard to the situation of the parts after 
they have descended in the cavity of the pelvis, it may be further noted, 
that certain intermediate or modified presentations may possibly occur. 
Brow presentations, for example, are described by many writers, and, 
in so far as we may judge from comparative measurement and mechan- 
ism, are to be admitted as possible. They must, however, be always 
looked upon as of the most unfavorable nature, and one of the most 
formidable objections to Baudelocque's operation was the risk of thus 
converting an unfavorable presentation into one which was, perhaps, 
even more so, should the attempt at artificial rectification be arrested 
midway in its course. A thorough knowledge of the mechanism of 
ordinary labor will be the best guide to the management of any such 
exceptional cases as may offer themselves in the course of practice. 

We have attempted throughout, in the description which has been 
given of the four positions of the face, to indicate the strong analogy 
which exists between them and the ordinary positions of the cranium, 
which are so familiar to all. The prominence of the chin, therefore — 
be it once more remarked — is the analogue of the occiput. This is 
more clearly shown in the following tabular statement, which is drawn 
up with the view, not only of showing the relation between facial and 
cranial positions, but also of enabling the student to store the facts 
in his memory, in such a form as may be most available for prac- 
tical emergencies in any presentation of the cephalic extremity of the 
child. 



324 



PELVIC PRESENTATIONS. 



[CHAP. 



Tabular Arrangement of the Presentations and Positions 
of the Cephalic Extremity of the Foetus. 



Occipito- 
anterior I 
Positions. 



Cranium or Vertex. 

I I. In Right Oblique Diam- 
eter ; forehead to right 
sacro-iliac synchondro- 
sis. 



Occipito- , 
Posterior 
Positions.! 



II. In Left Oblique Diam- 
eter ; forehead to left 
sacro-iliac synchondro- 
sis. 

till. In Right Oblique Di- 
ameter ; forehead to- 
wards left ilio-pec- 
tineal eminence. Usu- 
ally rotates into the 
second. 

IV. In Left Oblique Diam- 
eter ; forehead towards 
right ilio-pectineal emi- 
nence. Usually rotates 
into the first. 



Mento- 
posterior 
Positions. 



Mento- 
anterior 
Positions 



Face. 

I. In Right Oblique Di- 
ameter ; forehead to- 
wards left ilio-pecti- 
neal eminence. Ro- 
tates into the fourth. 

II. In Left Oblique Diam- 
eter ; forehead to- 
wards right ilio-pec- 
tineal eminence. Ro- 
tates into the third. 



III. In Right Oblique Di- 

ameter ; forehead to 
right sacro-iliac syn- 
chondrosis. 

IV. In Left Oblique Diam- 

eter ; forehead to left 
sacro-iliac synchon- 
drosis. 



In Cranial Positions, therefore, the third rotates into the second, and 
the fourth into the first; while in Facial, the second rotates into the third, 
and the first into the fourth. 



CHAPTEE XIX. 

PELVIC PRESENTATIONS. 

the practice of the past — the pelvis a natural presentation — DORSO- 

ANTERIOR AND DORSO-POSTERIOR POSITIONS — BREECH PRESENTATION; FOUR 
POSITIONS OF — FIRST POSITION OF THE BREECH : ROTATION: PASSAGE OF THE 
BUTTOCKS: DESCENT AND BIRTH OF THE SHOULDERS: DIFFICULT PROGRESS 
OF THE HEAD, AND MECHANISM OF ITS EXPULSION — SECOND POSITION OF THE 
BREECH — THIRD POSITION OF THE BREECH : BIRTH OF THE LOWER PORTION 
OF THE TRUNK, AND OF THE SHOULDERS: ROTATION OF THE FACE BACKWARDS, 
AND MECHANISM OF THE BIRTH OF THE HEAD; EXCEPTIONAL TERMINATIONS 
— FOURTH POSITION OF THE BREECH — SPECIAL RISK OF PELVIC PRESENTATIONS 
— DIAGNOSIS AND PECULIARITIES — KNEE AND FOOTLING CASES — MANAGEMENT 
OF PELVIC PRESENTATIONS — NATURE OF ASSISTANCE TO BE RENDERED — USE 
OF THE FILLET, VECTIS, AND BLUNT HOOK — INDISCRIMINATE DRAGGING ON THE 
LOWER LIMBS TO BE AVOIDED — TREATMENT OF CASE WHERE ARMS PASS UP 
ALONGSIDE HEAD — MANAGEMENT OF THE FUNIS — INDICATIONS OF IMPENDING 
DEATH OF THE CHILD — MANIPULATION FOR EFFECTING SPEEDY DELIVERY OF 
THE HEAD — USE OF THE FORCEPS. 



Although the writer of the obstetrical memoranda which were 
attributed to Hippocrates recognized the oval position of the child in 



XIX.] PELVIC PRESENTATIONS. 325 

the womb, and illustrated the impossibility of delivery in cross birth 
by the graphic simile of the olive in the neck of an oil jar, he strangely 
enough, as has already been mentioned, omitted to perceive the full 
force of his illustration. For, as every oval has two ends, he ought to 
have concluded that the fetal oval could pass naturally with either of 
these in advance, as the olive might be extracted from the jar. Failing 
to observe this, however, the ancients believed that presentations of the 
pelvic extremity were abnormal, and should in all cases be rectified by 
artificial aid. The result of such a mode of practice as this points to — 
which obtained throughout a period of several centuries — is looked at 
by the modern obstetrician with horror, on account of the fearful sacri- 
fice of human life which such a procedure must have involved. There 
is nothing, indeed, in the history of Midwifery comparable to this; 
and the idea of turning by the head in all cases of pelvic presentation 
is one so repugnant to every principle of the science and art of obstetrics, 
that it is difficult to conceive by what perversion of reason a blunder 
so fearful could have been perpetrated. Certain it is that, until the 
revival of anatomy by Vesalius, and even for some time after the art 
of printing had been discovered, the practice recommended in pelvic 
presentations was that which has just been indicated as dating from the 
time of the ancients. 

It is to Ambroise Pare that we owe the correction of this monstrous 
error, and from his day these presentations have always been recognized 
as natural. Although much more dangerous to the child, they are 
attended with no increase of risk to the mother. While, however, we 
prefer to consider presentations of the pelvic extremity as natural, it 
must be noted that many writers have thought it necessary to classify 
them as preternatural, an opinion which has given rise to much con- 
troversy, an analysis of which would serve no good or useful purpose. 
The pelvic end of the foetus is made up of certain anatomical elements 
which may present themselves in various combinations. The ordinary 
presentation is that in which the foetus preserves its usual intra-uterine 
attitude, with the limbs flexed, but with its axis inverted, so that the 
presenting part is the breech. If, however, the inferior extremities 
become separated from the trunk, and thus occupy the inferior segment 
of the uterus, we may have other presentations which fall under the 
same category, such as presentation of the knees or of the feet, or of one 
knee or one foot. The classification, therefore, of possible positions 
may be multiplied by a little ingenuity to such an extent as to render 
the subject an extremely complicated one, and its study a wearisome 
task. Here, again, we owe much to the indefatigable industry of 
Naegele. For it was he who first showed that, although we may sub- 
divide the positions ad infinitum, all pelvic presentations may, in so far 
as the mechanical phenomena of labor are concerned, be reduced to two 
classes according as the dorsal or abdominal surface of the child is 
turned forwards within the womb. We shall now proceed, therefore, 
to the description of the positions of the breech, which will suffice for 
all possible presentations of the pelvic extremity. Certain peculiarities 
attach to cases of knee and footling birth, which, being of a practical 
nature, will receive a brief notice in the proper place. 



326 PELVIC PRESENTATIONS. [CHAP. 

The structures which form the breech of the child are of a much 
softer and more yielding nature than the cranium, and are, therefore, 
within certain limits, more plastic and susceptible of adaptation to the 
parts through which they have to pass. Parturition is not the less on 
that account governed by fixed mechanical laws, according to which the 
parts enter, pass through, and emerge from the pelvic and parturient 
canal. To the consideration of these we now pass. In presentation of 
the breech we find no less marked a preference for the oblique diame- 
ters than in the case of the cranium, so that the child assumes a position 
with its back or belly forwards, and turned at the same time either to 
the right or to the left. The two main divisions of all such cases then 
are, according to Naegele and subsequent observers, dorso-anterior and 
dorso-posterior positions, the former being more frequent in the pro- 
portion of three to one. As each of these implies a possible position 
of the transverse or long diameter of the breech in either oblique diam- 
eter of the maternal pelvis, we may here, as in cranial and facial cases, 
detail four positions of the breech as follows : 



Dorso- Anterior, 



DORSO-POSTERIOR, 



( „. , D ... f Breech in Left Oblique Diameter; 

1 rirst Position. < , ~. , , . „ ^ , ' 

J ' [ left trochanter forwards. 

\ c 7 D •,• ( Breech in Right Oblique Diameter ; 

1 second Position. < . ,, , \? *. * j 

I. - l right trochanter forwards. 

/rm • ■, n •,• [Breech in Left Oblique Diameter ; 

Third Position, < . . . , , , „ 1 , 

' ( right trochanter forwards. 

j? .47 p '4' f Breech in Right Oblique Diameter ; 

I £* OlLVtll A Sit 1071. "\ l n. , 1_ j /» T 

^ ' ( left trochanter forwards. 



The breech is recognized, on a digital examination, by the ischial 
tuberosities, between which the genital organs, male or female, may be 
distinguished. As the parts are, however, frequently much distorted 
by the formation of the caput succedaneum, it is not always so easy for 
the beginner to recognize the presentation as he may perhaps imagine. 
He may, in a hurried and imperfect examination, very readily mistake 
the tuber ischii, which his finger first touches, for the prominence of 
the shoulder, and the female genital organs for the fold of the axilla. 
It is well, therefore, that in every case he should make a leisurely ex- 
amination, in order to insure the accuracy of his diagnosis. The 
genitals, occupying a situation between two osseous prominences, one 
of which is usually considerably lower than the other, can scarcely be 
mistaken ; and, in the case of the male, the scrotum is generally tume- 
fied. But if any doubt should arise, this is set at rest if, in addition to 
the parts named, he recognize the anus, the point of the coccyx, and the 
unequal osseous surface of the back of the sacrum. To this last point 
Cazeaux attaches considerable importance. At the commencement of 
labor, or even before it has come on, it may be possible to recognize a 
breech presentation by palpation of the abdominal tumor, which, when 
the walls of the belly are thin and relaxed, enables us to recognize the 
general outline of the child, with the rounded resistant cephalic ex- 
tremity turned towards the fundus and inclined a little to either side. 
The pulsations of the foetal heart are heard on a somewhat higher 






XIX.] FIRST POSITION OF THE BREECH. 327 

level, near the umbilicus. The absence in the vagina of the firm and 
smooth globular head, which generally occupies the lower segment of 
the uterus, would further corroborate such observations as the above. 
The presentation is, at this stage, higher than usual, and often beyond 
the reach of the finger ; but, in knee and footling cases, the knee or 
heel may be felt lying against the most dependent part, and retreating 
before the pressure of the finger. In its general shape and external 
appearance, the uterus is not sensibly altered. 

Presentation of the pelvic extremity is by no means a rare occur- 
rence, as it is met with once in about 45 mature births ; and in prema- 
ture delivery it is, for reasons formerly stated, much more frequent. 
In 80 cases observed by Dubois, 54 were ordinary breech positions, 
and in 26 the feet descended in advance. Madame Lachapelle only 
saw the knees presenting once in 3445 instances of labor, and in the 
statistics of the Lying-in Hospitals of Wurzburg and Prague, we find 
but one case in 9274. The breech is, however, not only the most 
frequent, but the most favorable of the pelvic presentations. For al- 
though at first sight it might appear that a footling or knee might, on 
the principle of the wedge, be a more favorable arrangement mechani- 
cally, an observation of the whole process at once shows that this is 
not the case. The broad breech, increased in bulk by the flexion of 
the thighs, performs a most important function in dilating the passages 
for the safe and rapid progress of the head, during the latter and more 
critical period of the labor ; and as it is very evident that this will be 
more effectively done by the breech than by the footling presentation, 
the former is, from a mechanical point of view, undoubtedly the most 
favorable. 

First Position of the Breech. — Of all the possible positions of the 
pelvic extremity this is the most common. In it, the transverse or 
long diameter of the breech occupies the left oblique diameter of the 
brim, so that, as the back of the foetus is turned forwards, it is the left 
ischial tuberosity which is lowest in the pelvis, and upon which the 
finger impinges on examination. The position is shown in the accom- 
panying engraving. Backwards, and in the direction of the left sacro- 
iliac synchrondrosis, another similar projection is reached, and between 
the two, in a direction corresponding to the right oblique diameter, is 
a sulcus or depression, in which may be recognized, from before back- 
wards, the coccyx, the anus, and the external genital organs. In pro- 
portion to the resistance offered to the breech in its descent, there is an 
increase in its obliquity, which brings the left buttock still more in 
advance, precisely as occurs in the descent of the occiput. When the 
breech reaches the floor of the pelvis, therefore, it is the left hip and 
posterior surface of the left thigh which comes upon the anterior ischial 
plane of the right side, while the right hip passes behind the left 
ischial spine, and comes into contact with the sacro-sciatic ligaments 
of the same side. 

A rotation now takes place which is in every respect analogous to 
the cranial rotation already described, the left buttock gliding down- 
wards, forwards, and to the left, along the ischial plane and the obtu- 



328 



PELVIC PRESENTATIONS. 



[CHAP. 




First position of the breech. 



rator interims, while the right buttock performs the corresponding 

movement from left to right 
fjg. 116. towards the hollow of the sa- 

crum. There is not in this case 
— as a comparison of the rela- 
tive measurements will show — 
the same imperative necessity 
for rotation which obtains in 
the case of the head. But, in 
its birth, it follows the same 
mechanical law, with this dif- 
ference only, — that the rotation 
is, in the case of the breech, 
more rarely complete into the 
antero-posterior diameter than 
occurs when the head is the 
presenting part. It might be 
supposed, following the analogy 
of the mechanism of the occip- 
ito-anterior positions of the 
vertex, that the left buttock 
passed upwards and forwards 
under the pubic arch, while the 
right swept over the perineum. 
Such, however, is not the usual mechanism of the process. The left 
buttock, indeed, moves forwards to the arch, but at this point it is 
arrested and forms a centre, upon which the right buttock describes 
the arc of a circle, from before backwards on the distended perineum, 
so that, in the act of birth, it takes precedence of the left, which passes 
immediately afterwards. The long diameter still preserves to the last 
a certain amount of its obliquity, so that the right buttock is directed 
a little to the left of the middle line, and, so soon as it has passed, the 
feet and knees slip down, and with the movement of extension of the 
thighs the lower part of the trunk is born. The belly of the child 
thus lies towards the right thigh of the mother. No marked move- 
ment of restitution occurs at this stage, because the shoulders are de- 
scending in the same oblique diameter as was occupied by the breech. 
If, however, the trunk of the child does not participate in the rotation 
of its pelvis, a certain degree of restitution may occur to relieve the 
twisting of the vertebral column. 

The thorax now occupies the pelvic cavity. The superior extremi- 
ties, if normally situated, are in contact with the anterior and lateral 
parts of this region of the trunk. The long diameter of the shoulders, 
occupying like the breech the left oblique diameter, descends under the 
influence of successive pains. When the resistance of the pelvic floor 
is fully encountered, a movement is executed in every respect similar 
to that which is observed in the passage of the breech. The left 
shoulder comes forward towards the summit of the pubic arch, but is 
there arrested, so that the right sweeps over the perineum, and is born 



XIX.] 



BIRTH OF THE BREECH. 



329 



in advance of its fellow, as shown in Fig. 118. It happens, not un- 
frequently, that one or both of the arras slip up during the descent of 
the trunk, and become applied to the sides of the child's head (see Fig. 
119), an accident which, in a pelvis below the average in its measure- 
ment, may give rise to considerable obstruction and delay. The origi- 
nal attitude of the head with reference to the trunk, in all breech cases, 



Fig. 117. 




Birth of the breech. 



is with the chin flexed towards the sternum, which permits of the ex- 
pulsive force being communicated to the trunk to the greatest mechani- 
cal advantage. Any movement of extension which may occur, tends 
not only to disturb the conditions upon which a speedy labor depends, 
but may also, by allowing the hands to slip between the chin and the 
sternum, and thence to the side of the head, interpose a very serious 
barrier to the accomplishment of the labor, more especially if, as some- 
times happens, one becomes locked behind the head, and between it 
and the pubis. 

As the shoulders are passing through the outlet of the pelvis, the 
head descends in the right oblique diameter. The point of essential 
distinction between pelvic and cephalic presentations becomes manifest 
at this stage. In the latter, the difficulty terminates with the birth of 
the head and the passage of the shoulders, but in the former it is widely 
different. The passage of the breech is not attended with any special 
difficulty ; nor is the passage of the shoulders long delayed. But, in- 
stead of the difficulty ceasing with the birth of these parts, it becomes 
increased, and the really anxious and critical time of the labor now 
begins. For not only has the most unyielding part of the foetal oval 
still to pass, but it has to pass under circumstances which necessarily 
imperil the life of the child. Beyond a certain point, indeed, delay in- 



330 



PELVIC PRESENTATIONS. 



[CHAP. 



volves death to the child, so that the skilful management of this stage 
may be said to be one of the most important practical duties of the 
accoucheur. A cause which, at this moment, increases the risk, is the 
failure of expulsive force. This does not imply so much a failure of 



Fig. 118. 




Birth of the shoulders. 



expulsive action as that, the uterus being now nearly empty, its pro- 
pulsive energy is brought to bear upon the head at great mechanical 
disadvantage ; and it is difficult to see how, but for the contraction of 
the vagina, and of the muscles at the floor of the pelvis, nature could 
ever complete a case of pelvic presentation. In the position at present 
under consideration, the head descends with the forehead turned to- 
wards the right sacro-iliac synchondrosis, and a little in advance. The 
occiput is turned towards the left ilio-pectineal eminence, and after 
rotating towards the subpubic arch, is there arrested until the chin, 
nose, forehead, and vertex sweep successively forwards and upwards 
over the distended perineum. Fig. 120 shows the head in this position 
immediately prior to the final act which terminates the second stage of 
labor. 

Second Position of the Breech. — In this, the position is also dorso- 
anterior ; but, instead of occupying the left as in the position above de- 
scribed, the pelvis descends in the right oblique diameter. It is there- 
fore the right ischial tuberosity which presents, and the right buttock 
which descends in advance as far as the pubic arch, being directed to- 
wards it by the anterior inclined plane on the left side of the pelvis. 
The left hip sweeps over the perineum, and the shoulders descending 
in the right, and the head in the left oblique diameters, are successively 
expelled by a mechanism which is in all respects identical with that 



XIX.] 



SECOND POSITION OF THE BREECH. 



331 



which obtains in the first position, only in the contrary direction as re- 
gards the various rotatory and other movements. At first it seems 



Fig. 119. 




Arm displaced upwards. 



strange that this should be less frequent than the first position, and 
that nature should prefer the left oblique diameter in breech cases to 



Fig. 120. 




Birth of the head. 



the right ; and this too would almost seem to throw doubt upon the 
opinion we have expressed that she prefers the right oblique in cranial 



332 PELVIC PRESENTATIONS. [CHAP. 

presentations, in order to avoid the left, which is encroached upon by 
the rectum. But, even here, if we watch the case to a termination, we 
find nature apparently guided in a majority of cases by the selfsame 
law. For, as we have already seen, the really critical and important 
moment of a breech case is that during which the head passes through 
and out of the pelvis; and it is on this account that in the more com- 
mon first position the head is in the favorable diameter ; whereas, in 
the second, the head descends in the left, which is, as statistics would 
seem to show, more dangerous to the child, probably because detention 
of the head is more likely to occur. 

Third Position of the Breech. — Of 161 cases occurring at Heidelberg, 
121 had the back, and 40 the belly of the child turned forwards. This 
gives as nearly as possible a preponderance in favor of the two first 
positions, already set down at three to one. The two Dorso-Posterior 
positions, then, are of comparatively rare occurrence. 

In the Third Position, which occurs less frequently than any of the 
others, the breech lies in the left oblique diameter, which, as the back 
is turned towards the vertebral column of the mother, brings the right 
tuber ischii to the front, and deeper in the pelvic cavity. When it 
reaches the floor of the pelvis, the corresponding buttock glides along 
the right ischial plane, and attains the summit of the pubic arch, where 
it is arrested until the left ischium sweeps over the perineum, when 
the belly of the child is born towards the mother's left thigh. The 
shoulders descend in the same oblique diameter, and are expelled 
pretty much as in a dorso-anterior position. The head then enters the 
pelvis in the right oblique diameter, with the occiput towards the right 
sacro-iliac synchondrosis. In the great majority of cases, the termina- 
tion of this position is by a rotation which brings the occiput from the 
sacro-iliac synchondrosis to the obturator foramen on the right side, 
and the forehead from the obturator foramen to the sacro-iliac syn- 
chondrosis on the left side. In a word, the rotation is the same which 
converts a third into a second position of the cranium. This rotatory 
movement has, in some cases, been observed to take place at an earlier 
period in the labor. When that occurs, the movement takes its direc- 
tion from the original rotation, which brings the right buttock in 
advance. It passes then, from right to left, into the conjugate, and a 
little beyond it, and ultimately continues the movement in the same 
spiral direction, until the belly of the child looks almost directly back- 
wards. The trunk, in this case, participates in the rotation of the 
breech ; but if it does not so participate, the head itself, when subjected 
to the resistance of the pelvis, performs the extensive rotation which 
we have described. Whatever may be the course of labor in this 
position, the natural termination is a rotation into the second position. 
The head, therefore, whether the vertex or the breech presents, rotates, 
as a rule, from the third position into the second. 

Cases are occasionally observed in which the rotation above described 
does not take place, and the head comes into the world with the occiput 
turned backwards. The usual course in such a case is, that the head 
descends in the pelvis in a strong state of flexion, with the forehead 
and occiput turned to the anterior and posterior extremities, respectively, 



XIX.] 



FOURTH POSITION OF THE BREECH, 



333 



of the right oblique diameter. The usual movement of rotation brings 
the occiput along the right sacro-sciatic ligaments towards the hollow 
of the sacrum, and the forehead from left to right, under the subpubic 
arch. The original motion of flexion is then continued, so as to bring 
the face, forehead, and vertex, in succession, from behind the symphysis, 
while the occiput, around which as a centre, this movement has been 
executed, is the last part to escape. It would also appear, from cases 
which are recorded upon good authority, that the head in this position 
may escape by a movement which is not one of flexion, but of exten- 
sion. The occiput, in those rare instances, would seem to have preceded 
the forehead in its descent; the chin rests upon the lower part of the 
symphysis, and the occiput, vertex, forehead, and face successively 
emerge over the perineum, the 
depression between the chin and 



the trachea 
upon which 




being the centre 

the movement of 
extension occurs. 

Fourth Position of the Breech. 
— Of the two dorso-posterior 
positions of ..the breech, it is this 
which is more frequently met 
with. The long diameter of 
the hips occupies the right ob- 
lique diameter of the brim, so 
that, while the child sits, as it 
were, upon the brim of the pel- 
vis, its anterior surface looks 
forward, and to the right. The 
left trochanter is towards the 
left ilio-pectineal eminence, and 
it is consequently the left tuber 
ischii which is forwards, and 
stands lowest in the pelvis. The 
breech and shoulders descend 
as in the third position, each 
performing the same limited amount of rotation and external restitu- 
tion ; the head then arrives in the pelvis, in the left oblique diameter, 
the chin being in front of the right, and the occiput behind the left 
ischial spine. The head then rotates, under ordinary circumstances, 
from the fourth position into the first, the occiput travelling, as in the 
corresponding positions of the vertex, from the left sacro-iliac synchon- 
drosis, onwards along the left side of the pelvis, until it arrives at the 
subpubic angle, where it is arrested, and the face, forehead, and vertex 
sweep, as in the preceding presentation, forwards over the distended 
perineum. The same exceptional cases may also occur as in the third 
position, and we should therefore be prepared for the possible occur- 
rence either of complete rotation before the head descends to the brim, 
or of one or other of the occipito-posterior positions which have been 
described. 

All presentations of the breech tend therefore, as has been shown, 



Fourth position of the breech. 



334 PELVIC PRESENTATIONS. [CHAP. 

to terminate more irregularly than those of the head. The birth of the 
nates is perhaps attended with even less difficulty than when the head 
precedes, but the real difficulty is the speedy and safe passage of the 
latter. And it is indeed remarkable, not only in regard to the first 
position, but also the fourth, or more frequent of the dorso-posterior 
positions, that the head, in its descent by the normal path, avoids that 
oblique diameter which is contracted by the rectum. But whether this 
occurs or not, pelvic presentations are attended by special and greatly 
increased risk. This is much more so, however, in regard to knee and 
footling cases, than when the breech presents in the ordinary way. 
This is brought out very clearly by the statistics of 71,578 cases col- 
lated by Dr. Rigby from various sources. The nates presented once in 
every 78 cases, and the feet once in 108.5 : of the nates cases the child 
was born dead in the proportion of 1 to 3.8, and in the footling births 
1 to 2.8. Knee presentations are so rare that they need not be taken 
into consideration. 

Something must here be said in reference to the diagnosis of knee 
and footling cases, but as regards the mechanism according to which 
labor under such circumstances is accomplished, no special description 
is necessary, as it differs in no material respect from what has been 
described in regard to the breech. The mechanism of all pelvic pre- 
sentations is, in other words, essentially the same. Very little can be 
recognized with certainty, until the rupture of the membranes enables 
us to distinguish the various parts. The form of the bag of waters, 
upon which some have laid great weight in a diagnostic point of view, 
may certainly give rise to suspicion, although it can never by itself be 
of much importance. In all pelvic presentations, it is, as a rule, more 
pointed, and projects further into the vagina. In footling cases, the 
bag is long and sausage-shaped, and through it the foot or feet may be 
felt. When the membranes ultimately give way, the discharge of the 
liquor amnii does not take place with such a gush as in cranial positions, 
but on the other hand it is more continuous, and the drainage more 
complete. In cranial presentations, the head, acting like a ball-valve, 
hinders the liquor amnii from escaping, except in small quantities, in 
the intervals between the pains; but, when the irregular pelvic extremity 
presents, a more complete escape is permitted, which, by bringing the 
uterus to bear more powerfully and directly upon the surface of the 
child, no doubt increases the risk in all such cases. The foot is very 
liable to be mistaken by beginners for the hand, for although any one 
could distinguish between the two with the eyes shut, if he could bring 
the whole of his ten fingers to bear upon it, it is a very different matter 
when he attempts to recognize a part which can only be reached by a 
couple of fingers, and that possibly with difficulty. The length of the 
digits, and the mobility of the thumb as compared with the great toe, 
will prevent the possibility of doubt when we can recognize these points, 
but under circumstances of unusual difficulty, this may be impracticable. 
No single anatomical feature of the foot is, in difficult cases, so charac- 
teristic as the prominence of the heel. The dorsal surface of the hand 
may be mistaken for the instep and the fingers for the toes, but on the 
other side of the joint there is nothing in the hand which can be com- 



XIX.] MANAGEMENT OF PELVIC PRESENTATIONS. 385 

pared to the projection of the heel. If, therefore, we can pass one finger 
over the dorsum of the foot, and another over the heel, which enables 
us to grasp the extremity of the limb like the head of a crutch, we may 
be perfectly confident that it is a foot and not a hand with which we 
have to deal. And we would here observe, parenthetically, that this 
is one of many points, in regard to which the young practitioner should 
lose no opportunity of perfecting the tactus eruditus ; for a mistake here, 
which is acted upon by operative or other interference, may bring dis- 
credit upon him, and, what is worse, may directly lead to the most 
disastrous results for his patient. The determination of the position 
from a single foot is a matter in reference to which some doubt may 
exist. The general direction of the toes will however indicate the 
abdominal surface of the child, and if both feet should present, this is 
much more certain. We may, however, have to wait for the descent 
of the breech before we can be certain to which of the four positions it 
is to be referred. A single foot should always, if possible, be identified 
as right or left, which is very easily done, if it be sufficiently within 
reach, by placing the palm of the hand to the sole of the foot in the 
same manner as is pursued in identifying a single hand, as will be more 
particularly described afterwards. 

The risk to the mother in presentations of the pelvic extremity is in 
no way increased; for, admitting that the opinion generally expressed 
in regard to the tardy completion of the first stage is correct, we may 
assume that this is compensated for by the comparative ease with 
which the child makes its way through the passage. But the figures 
already quoted, which are confirmed by the experience of every one, 
show only too clearly that the risks to which the child is exposed are 
enormously increased. It is equally certain, — as, indeed, is further 
indicated by the figures alluded to, — that the risk is not the same in 
all cases of pelvic presentation alike, but is greatly increased in those 
cases in which the thighs are extended, and not flexed upon the trunk. 
The cause of this is to be found, as has already been observed, in the 
inefficient manner in which the canal is thus dilated for the passage of 
the head, which delays the completion of the labor at the critical mo- 
ment when, all being born but the head, it is arrested in the pelvis 
until the life of the infant is destroyed by suffocation. In an ordinary 
breech labor, the more complete dilatation of the parts reduces this risk 
to a considerable extent, but even under the most favorable circum- 
stances the risk is, as compared with cranial births, enormously in- 
creased. And it is none the less certain that, by prompt and skilful 
measures, the accoucheur will often have the gratification of saving 
lives which, if left to nature, would have inevitably been sacrificed. A 
thorough knowledge of the mechanical phenomena above detailed, is 
the first essential qualification which may lead to skill and judicious 
management in the treatment of all cases of pelvic presentation. In 
order thoroughly to understand the subject, however, we must view it 
under various aspects. While we have no difficulty, for example, in 
recognizing that, in many instances, assistance is necessary, we must 
not overlook the fact that injudicious interference is bad. We have to 
consider, therefore, not only what to do, but what not to do; for, an- 



336 PELVIC PRESENTATIONS. [CHAP. 

fortunately, many errors in practice have been committed, and as some 
have had the sanction of great names, it is doubtful whether on this 
subject sound practical views are entertained as invariably as they 
ought to be. 

Long after the preposterous idea of Hippocrates, alluded to in the 
beginning of this chapter, was exploded, views erroneous, but erroneous 
in a minor degree, obtained in reference to the treatment of presenta- 
tions of the pelvic extremity of the child. We thus find Williams, 
Hunter, and Smellie bringing down the feet when the breech presents 
at the beginning of labor; and we cannot wonder that this mode of 
procedure extended into the present century, although it has now hap- 
pily long fallen into disuse. The errors of the present day are thus 
rather of the nimia diligentia category than the grosser blunder allnded 
to; but, in regard to the presentations which we are now considering, 
it may with truth be said, that the subject is one which demands care- 
ful attention at the hand's of every one who would be an accoucheur 
and not a midwife, not less than the more familiar positions of the 
cranium. 

It may be inferred from what has already been said, that the duties 
and responsibilities of the accoucheur are, in the case of a pelvic pre- 
sentation, greatly increased. In a cranial case, while all goes well, we 
look to the issue without a shadow of apprehension ; and we absent 
ourselves, from time to time, without any consciousness of neglecting 
or evading a duty. But, when the pelvis presents, all is altered in this 
respect. The risk, be it again repeated, is a fetal, and not a maternal 
one ; but, as we cannot tell the moment at which our assistance may 
be required, we must be much more strict and continuous in our at- 
tendance ; and, so soon as the breech has descended in the pelvis, we 
must not leave the bedside of our patient until the delivery has been 
completed. This assiduity, on our part, does not involve, of necessity, 
any interference with the natural process. On the contrary, many 
cases will terminate happily without any aid afforded ; so that we have 
two important points before us for solution in every case : whether we 
are to interfere at all; and, if so, how, and at what time? 

Having fully satisfied ourselves of the exact position of the foetus, 
and thus recognized the manner in which the mechanism will probably 
be conducted, we simply wait and watch the issue. If nature takes 
the ordinary course, and the breech descends, whatever its original 
position may have been, in a satisfactory manner, we do not presume 
to interfere, by in any way hastening or aiding the labor. At this 
moment, there is no special risk to the child, and, indeed, the slower 
the dilatation. of the passage, the more effectual is that dilatation likely 
to be, and the safer and more rapid the subsequent birth of the head. 
So soon as the buttocks and lower limbs are born, we know that the 
critical period approaches ; and some anxiety is not unnaturally felt as 
to the subsequent progress of the case, as a condition now comes into 
operation, constituting one of the special dangers of pelvic births. 
This is compression of the umbilical cord, which, as the thorax ap- 
proaches the ostium vagina?, becomes jammed between the pelvic wall 



XIX.] OPERATIVE ASSISTANCE. 337 

and the unyielding cranium — a state of matters which, if complete and 
continuous, rapidly destroys the child, by interrupting the placental 
circulation. We should, at this stage, pull down a loop of the cord, 
thus obviating the probability of obstructed circulation by over-stretch- 
ing, and at the same time guide it, if possible, in the direction of either 
sacro-iliac synchondrosis — where the risk of pressure is least — choosing, 
if choice there be in the matter, that sacro-iliac synchondrosis which 
corresponds to the side of the child's head. Much useful information 
as to the prospects of the case is afforded by grasping the cord with the 
finger, so as to feel its pulsation. So long as this remains quite vigorous, 
the case is to be left entirely to nature; but we must repeat the obser- 
vation frequently, as the descent of the head may expose the cord quite 
suddenly to fatal pressure — a fact which it is of the highest importance 
immediately to recognize. The persistence or failure of funic pulsation 
are, in fact, the chief indications as to the necessity for operative 
interference. 

Exceptional circumstances, no doubt, may arise to call for assistance 
at a stage even earlier than that which we are describing. Long de- 
tention of the breech within the cavity, owing to disproportion of the 
foetal or maternal parts, or to inertia uteri, may call for action at an 
unusual period, on the same general principles as obtain in the case of 
obstructed cranial labor. Tiie operative procedure proper to breech 
cases is, however, peculiar ; and, if we fail, by the use of ergot or other- 
wise, to arouse the dormant energy of the uterus, or should w r e recognize 
an obstruction which natural efforts cannot overcome, we must be pre- 
pared to act with a view to speedy delivery. The forceps, being specially 
constructed for application to the foetal head, is not available. The 
vectis, however, applied over the flexure of one thigh, while the hand 
of the operator is applied to the other, may possibly succeed ; and the 
blunt hook is an instrument which has been frequently recommended 
in the management of such cases. No one can doubt the mechanical 
power of these, and especially of the blunt hook ; but the danger of 
bruising, and even lacerating, the parts of the foetus is not inconsidera- 
ble, so that such means should, if possible, be avoided. When the 
child is dead, and much force has to be employed, the blunt hook, and 
even the crotchet may be applied — the use of which instruments will 
be more particularly detailed when we come to consider obstetric in- 
struments and their use, under a special section. By the fingers alone, 
introduced over the groin upon the flexure of the thighs, the breech, in 
a very considerable proportion of ordinary cases, may be drawn down 
under the pubic arch, the operator remembering always, and imitating, 
as far as possible, the natural mechanism of the act. This is in all 
cases to be preferred as the safest ; but, should it fail, a second mode 
is still available, which is much safer than, and therefore to be pre- 
ferred to, any variety of instrumental delivery. What is required for 
the operation is a handkerchief, or, what we have found even more 
satisfactory, a skein of cotton yarn. One end of this is to be passed 
between the thighs and the abdomen, in the flexure of the groins, to 
the corresponding point on the other side, where it is to be seized and 

22 



338 PELVIC PRESENTATIONS. [CHAP. 

pulled down. 1 Id this we have a powerful fillet so adjusted that we 
may use a very considerable traction force without any risk of injury. 
It is sometimes possible — and the more so when the breech is high in 
the pelvis — to break up the presentation, by pulling down one leg. 
Should we employ this subsequently, for the purpose of traction, great 
care must be taken not to use too much force, otherwise dislocation or 
fracture may be readily enough produced. 

The rule, however, is, as has been said, that we should interfere in no 
way whatever until the breech and low r er part of the trunk have been 
born, when we direct our attention assiduously to the state of the cord. 
When the breech is born, and the legs lie between the thighs of the 
mother, and in footling cases, even before the passage of the breech, an 
almost irrepressible desire may possess the accoucheur to grasp the limbs 
and to bring the labor to a rapid termination. Such, it is to be feared, 
is not unfrequently the practice of those who have not taken some pains 
to master the mechanism of pelvic births. In many cases, doubtless, 
the result may be what is desired, but the hasty termination of the 
labor is thus purchased at an increased risk to the child. For the 
result of thus forcibly dragging down the body of the child is to sepa- 
rate, unless the uterine contractions are unusually strong and continuous, 
the chin from the sternum, against which it has been hitherto applied. 
The consequent extension of the head may thus result in a faulty posi- 
tion ; or, if the traction be continued, it may descend without under- 
going the natural movement of rotation proper to the original position. 
The possible result of this is only too obvious, and arises from the fact 
that under such circumstances the child's head is delayed in the pelvis 
longer than if we had left the case to nature, and thus, at the moment 
of all others at which speedy delivery is desired, the head is detained, 
and the child is suffocated, owing to the blundering ignorance of the 
operator. But this is by no means the only manner in which his mis- 
placed energy may defeat its own ends, for the separation of the chin 
from the sternum leaves a gap into which the hands are liable to slip 
from their position in front of the thorax, and from thence again to the 
sides of the head, which may thus, in a tight pelvis, be jammed at the 
brim. This, then, is an obvious error in practice which the young 
practitioner should carefully avoid, and in regard to which midwives 
should be specially instructed and cautioned. 

The posture of the hands, and even of the arms, by the side of the 
head is an occurrence which, quite independently of unskilful inter- 
ference, may spontaneously take place. Under all circumstances, it 
is an unfortunate complication, and requires, when recognized, imme- 
diate attention. So soon therefore, as the lower half of the trunk has 
been born, and the cord has been looked to, we pass up the finger to 
ascertain the relative position of the arms. Should these be in the pos- 
ture of which we have just spoken as the natural one, no interference 
whatever is required, but if they are applied to the sides of the head, 

1 In cases where this cannot easily be done, an elastic catheter, or some instru- 
ment'of the nature of that which is used for plugging the posterior nares, might be 
advantageously employed. 



XIX.] BIRTH OF THE HEAD. 339 

it will be proper to bring them clown singly. Selecting that one which 
is most within reach, a finger is to be hooked over the humerus, close 
to the elbow-joint, when the arm is to be gently drawn forwards, so as 
to cause the forearm to sweep over the anterior surface of the child. If 
dragged down roughly, and without any reference to direction, fracture 
of the humerus may occur, as has indeed often taken place in the hands 
of the ignorant or unskilful. The one arm being released, the head 
will probably descend a little further, and the other, coming thus more 
within reach, is to be treated in the same manner. We must be careful, 
during the passage of the shoulders, that the perineum is neither dis- 
tended in such a manner, nor in such a direction, as to endanger its 
integrity. The head, after the birth of the shoulders, now occupies 
the cavity of the pelvis, and the face, in almost all cases, will be found 
to have rotated into the hollow of the sacrum. 

This is the stage of greatest clanger, and that at which the life of the 
child is most frequently lost. Consequently, this is the moment which 
requires the most constant attention, and at which assistance has gen- 
erally to be afforded. The powers of nature are, in a certain propor- 
tion of cases, quite sufficient to complete the delivery, so that even 
here there exists no necessity for operative interference as a point of 
routine duty. We must, still, therefore, be guided by the circum- 
stances of the case, and no single sign affords us more reliable informa- 
tion as to the urgency of the symptoms, than, as before, the funic pul- 
sation. The cord, however, now becomes exposed to more powerful 
pressure, and, at the same sime, the function of the placenta is seriously 
interfered with, if not wholly arrested. The absence, in breech cases, 
of the not inconsiderable quantity of liquor amnii which remains in 
ordinary presentations till the last, allows of the firm compression of 
this organ between the head of the child and the uterine walls ; and, 
even should not this take place, the great contraction of the uterine 
vessels permits of but a scanty supply of maternal blood for the oxy- 
genation of that of the foetus. This, then, may truly be called a crit- 
ical moment, in which, although placental respiration has all but ceased, 
aerial respiration is as yet impossible. A life trembles in the balance, 
and a few minutes at furthest will decide its fate. Impending death 
from asphyxia is indicated in such cases, not only by a failure in the 
circulation of the cord, but by failure of the heart's action as observed 
by the stethoscope, and by convulsive movements of the respiratory 
muscles. Such spasmodic attempts to fill the lungs with air are of the 
nature of reflex actions, excited probably by the contact of carbonated 
blood with the nervous centres. They indicate, therefore, impending 
suffocation, and call for immediate action. It is assumed, of course, 
that before matters have gone so far as this, we have in readiness such 
restoratives as may be approved of, hot and cold water, and the forceps 
— everything in fact which may be requisite, whether for the delivery 
of the child, or its restoration should it be born, as frequently occurs, 
in a state of suspended animation. 

When the signs just mentioned indicate that the moment for opera- 
tion has arrived, w T e must act without a moment's delay, a few seconds 
making all the difference between success and failure, life and death. 



340 



PELVIC PRESENTATIONS, 



[CHAP. 



The body and shoulders must not be grasped and pulled directly down- 
wards, as is sometimes done. To do so would probably defeat our ob- 
ject, by pulling down the occiput towards the pubic arch, instead of 
favoring the natural movement of flexion ; and, besides, forcible trac- 
tion of the neck is by no means free from the risk of causing instant 



Fig. 122. 




Artificial delivery of the head in breech cases. 

death by injury to the spinal marrow. The following simple manoeuvre 
answers admirably in ordinary cases; and will rarely fail to release the 
head. The body of the child rolled in a napkin is laid along the right 
forearm, which is then carried upwards between the thighs, so as to 
bring the back of the child quite towards the abdomen of the mother. 
Very gentle traction is all that is necessary to combine with this move- 
ment, in order to permit the extraction of the head, which is mainly 
effected, indeed, by the flexion of the neck which is thus encouraged. 
Should this fail, the same movement may be combined with extractive 
force, applied directly to the head by one or two fingers in the child's 
mouth, or what is better and safer, two fingers applied to the superior 
maxilla, one on either side of the nose. Some of the best authorities 
recommend a simple method by which all traction on the neck is 
avoided. In this, which is represented in the annexed engraving, two 
fingers of the left hand are introduced, as above described, while the 
occiput is pushed upwards behind the symphysis by the corresponding 
fingers of the right hand: the movement of flexion essential to de- 
livery is in this way effected, while the face and forehead are drawn 
forwards along the distended perineum. By such a proceeding, some 
have succeeded in establishing respiration, even before the head was 
born, and with this object in view, Dr. Bigelow has recommended the 
use of a flat flexible tube, which is to be passed within the vagina into 
the mouth of the child. All these manoeuvres must be varied, in cases 



XX.] TRANSVERSE PRESENTATIONS. 341 

of occipito-posterior and other exceptional positions, in accordance with 
the natural mechanism of each case. 

If, however, the resistance is unusually great, we must, in preference 
to dragging upon the neck, apply the forceps without delay to the sides 
of the child's head, and thus complete the delivery. If the child does 
not at once breathe, the usual means described under suspended anima- 
tion must be adopted and persevered in, so long as the slightest chance 
remains of preserving the life of the infant. Any exceptional circum- 
stances which may constitute impediments to delivery, must be man- 
aged on general principles ; and, in extreme cases, it may even be 
necessary to perforate behind the ear, and allow the contents of the 
cranium to escape. Should the child be dead, many of the precautions 
above detailed will of course be unnecessary. 



CHAPTEE XX. 

TRANSVERSE PRESENTATIONS: COMPLICATED 
PRESENTATIONS. 

transverse presentations : — the arm or shoulder the presenting part — 
causes of — signs of, before and during labor — premature rupture 
of the membranes to be avoided — dorso- anterior and dorso-poste- 
rior positions — determination of exact position by observation of 
the hand — probable course of an unaided case — occurrence of spon- 
taneous evolution — spontaneous expulsion — methods of operative 
assistance: period of labor to be selected: cephalic version: poda- 
lic version: method of combined external and internal manipula- 
tion: special difficulties — procedure modified if child dead — 
compound or complicated presentations — hand and head — hand and 
foot, etc. — general management of these. 

In the Cross Birth of Hippocrates, the axis or long diameter of the 
foetal oval is thrown across the womb — the most unfavorable position 
which could by any possibility be selected. There is scarcely a point 
on the surface of the trunk of the body in regard to which we may say 
that its presentation at the os uteri is impossible, and it is not to be 
wondered at, therefore, that some writers have described an infinite 
variety of Transverse Presentations. Experience has, however, shown 
that, whatever may be the case with a premature or putrid foetus, the 
presentation of a mature and living child, which has unfortunately 
assumed this position, is generally a presentation of the arm and 
shoulder from the first. And, moreover, in the exceptional instances in 
which some portion of the dorsal, thoracic, or abdominal surfaces pre- 
sents, it has been found that these are usually converted into shoulder 
or arm presentations by the descent sooner or later of those parts. For 
these reasons, and for this additional one — that the mechanism in all 



342 TRANSVERSE PRESENTATIONS. [CHAP. 

transverse cases is essentially the same — cases of cross birth may be 
considered solely as arm presentations ; and, when these have been 
fully described, it will be found that little remains to be specified in 
regard to the other possible presentations of the trunk. In point of 
fact, it is to presentations of the arm or shoulder alone that the terms 
"faulty" or "preternatural" are properly applicable. According to 
the elaborate statistics of Dr. Churchill, the superior extremities enter 
the pelvis in advance of the rest of the foetus once in 231f cases. 

The Causes of transverse presentation are, although obscure, probably 
somewhat less so than in the case of the breech. Any fault or deformity 
in the structure of the pelvic brim, which may act by preventing the 
descent of the head into the cavity, may turn aside, towards the iliac 
fossa, that extremity of the foetal ovoid, when the shoulder may slip 
down and take its place. In like manner, an unusual quantity of 
liquor amnii may, by destroying the ovoid form of the uterus, indi- 
rectly encourage the displacement in question ; while uterine obliquity, 
and premature expulsion of the foetus are also admitted by most writers 
as circumstances which may possibly act in a similar manner. The 
unfortunate tendency to a recurrence of this, in women who have 
already had a child or children presenting by the superior extremity, 
would almost seem to indicate that some anatomical peculiarity of the 
parts may be the cause ; and it was this which led Wigand to suppose 
that the form of the uterine cavity was the determining cause, and that, 
in those cases in which cross birth occurred, the transverse diameter 
of the uterus was in the first instance augmented, the long diameter of 
the cavity being thus relatively diminished. 

There are signs which, when distinct, may lead us, before the occur- 
rence of labor, to suspect the existence of a transverse presentation; 
but, until the presenting part comes within reach of the finger, it is 
generally a matter of considerable difficulty to form a confident opinion. 
The increased attention which has of late — more particularly in the 
German schools — been given to the study of abdominal palpation 
promises, however, to add precision to our diagnosis in this and other 
similar conditions where the pregnancy is sufficiently advanced and the 
abdominal walls are not unusually thick. In most cases, the belly of 
the woman is peculiar in shape, and elongated in a transverse direction ; 
and, if the abdominal walls are lax and thin, we may recognize a tumor 
in each iliac fossa, one of which is more resistant and spheroidal, and 
the continuity between which may be established on palpation. It is 
sometimes possible to distinguish the hand, elbow, or shoulder, through 
the anterior wall of the uterus, from the vagina ; but, generally speak- 
ing, when we discover the presenting part in this situation, the most 
we can say is that we feel a part which resembles the shoulder. Such 
an observation, however, associated w T ith careful abdominal palpation, 
may point to a quite definite conclusion. The stethoscope gives us no 
reliable information ; but there are cases, as Cazeaux observes, in which 
our diagnosis receives confirmation from this source. " If," he says, 
"the vaginal examination has resulted in the recognition of a portion 
of the foetus which is of small bulk, and if we perceive the pulsations 
of the heart in the hypogastric region, we may almost certainly con- 



XX.] SIGNS OF TRANSVERSE PRESENTATION. 343 

elude that it is the superior extremity. If we heard the heart at the, 
level of the umbilicus, it would in all probability be a leg." It hap- 
pens, even more frequently in transverse than in breech presentations, 
that it is impossible to reach any portion of the fetus with the finger 
alone in the earlier stages of labor; but, in some of these, the nature 
of the case will be recognized by introducing a portion of the hand. A 
marked effect of the height at which the foetus stands, is slow, and 
comparatively painless dilatation of the os ; and, when the bag of waters 
forms, it is, as in the case of the breech, very different in shape from 
that which precedes the head. In transverse presentations, the shoulder 
is the part which usually offers itself at the os uteri ; but, as a consid- 
erable period often elapses before it comes within easy reach of the 
finger, it is often not recognized until labor has made some progress — 
a fact which bears in an unfortunate manner, as we shall see, upon the 
ultimate issue of the case. 

It is, indeed, of the very highest importance that, if we have to deal 
with a cross birth, we should recognize the presentation as soon as it is 
possible to do so ; so that the moment we discover a shoulder, an arm, 
or a hand, we should not desist until we have exactly, and to our per- 
fect satisfaction, ascertained the position of the child. The prominence 
of the shoulder may be confounded with that of the tuber ischii, but 
may readily be distinguished by the absence of a similar tuber, at a 
little distance, with the genital organs between : and, should this nega- 
tive evidence not be deemed sufficient, the finger passed towards the 
axilla, so as to feel the ribs, will remove, if they can be reached, such 
doubts as may remain. Care must be taken, in such manipulation as 
may be necessary, to avoid rupturing the membranes ; for, so long as 
the child is not forced down upon the brim, and these remain intact, 
they are probably fulfilling their normal function of dilating the os, a 
process Avhich should not, if possible, be interfered with. But, should 
the membranes be ruptured, or the shoulder be forced downwards into 
the cavity of the pelvis, and if we are still in doubt, it will be proper 
cautiously to pull down the arm and hand, which enables us not only 
to make snre of the presentation, but to recognize the particular position 
by a simple method to be hereafter described. There is no evidence 
that this procedure has any bad effect upon the progress of the case or 
otherwise, and the unanimous opinion of the most experienced accouch- 
eurs is that, if carefully done, it is quite free from risk. But, even if 
a certain amount of risk necessarily attached to the operation, we would 
be perfectly justified in incurring it, in preference to attempting the 
management of the case without certain knowledge as to the position of 
the child. Some difficulty might occur in distinguishing the parts if 
not within easy reach. The manner in which the hand is to be made 
out under such circumstances has already been referred to in the pre- 
ceding chapter; but if, as will generally be observed, the arm hangs 
down into the vagina, there can be no difficulty whatever in distin- 
guishing it from the lower extremity even by the inexperienced. The 
anatomical characters of the knee and elbow would enable us to dis- 
tinguish also between these parts in the unlikely event of such a diffi- 
culty arising. 



344 



TRANSVERSE PRESENTATIONS. 



[CHAP. 



We have alluded to the caution to be exercised in manipulating, so 
as to avoid premature rupture of the membranes. There is, however, 
one advantage in this mode of procedure to which we have not alluded : 
this is the possibility of rectification of the transverse position. This 
has been observed by competent persons too often as a spontaneous 
occurrence to admit of doubt as to its being an exceptionally fortunate 
issue of the difficulties of such a case; but it must be manifest that no 
such alteration in the axis of the child can occur when the waters have 
drained away, and it is grasped firmly by the uterus and forced in part 
into the cavity of the true pelvis. And not only this, but we know by 
experience that the change may, in favorable circumstances, be effected 
by a method, to be afterwards described as that of Dr. Braxton Hicks, 
or, if the os is inaccessible by the finger, even more simply by external 
manipulation alone, after the method of Wigand. 

If we except certain complicated and unusual cases, to be afterwards 
alluded to, we may refer all transverse presentations to two varieties, — 
Dorso- Anterior and Dorso-Posterior — of which the former is more fre- 
quent in the proportion of two to one. In dor so-anterior positions the 



Fig. 123. 



Fig. 124. 




Transverse presentation. — Dorso-anterior. 



Transverse presentation.— Dorso-posterior. 



back of the child is, as in the corresponding positions of the pelvic 
extremity, turned forwards. But, as the head may lie either to the 
right or to the left, there are thus two varieties of this position, in one 
of which, the head being to the left side of the mother, the right 
shoulder presents ; while in the other, the head is to the right, and 
consequently the left shoulder is the presenting part. These varieties 
bear no relation whatever to the pelvic diameters. Nor, if we consider 
that they are preternatural as regards the uterine diameters, can we 
even admit that they bear any such possible or practical relation to 
these, as would warrant us in placing them in the same category as the 
presentations of the ends of the foetal ovoid which we have hitherto been 
considering. There is here no question — primarily at least — of oblique, 
transverse, or conjugate diameter, so that a separate description of the 
two varieties of dorso-anterior position is quite unnecessary. The same 



XX.] DIAGNOSIS OF POSITION. 345 

remark applies to the dorso-posterior position, which in like manner 
offers itself for consideration under two varieties. In one, the head is 
to the right, and the right shoulder presents ; in the other, the head is 
to the left, and the left shoulder presents. As regards the two princi- 
pal positions mentioned, as Avell as their varieties, it is unnecessary to 
enter upon any elaborate description, as the management is in all cases 
essentially the same. The nature of the operative procedure which, in 
the great majority of instances, is necessary in the treatment of trans- 
verse presentations, renders it important that we should begin by 
ascertaining the exact position of the foetus. Indeed, should we make 
a mistake in this particular, we know of a certainty that our error adds 
to the maternal risk, which is already considerable. Of great impor- 
tance, therefore, is it that we possess the power of discrimination between 
the four positions which have been alluded to. 

The points which we wish to ascertain are — to which surface of the 
womb, anterior or posterior, is the Back of the child turned ? and to 
which side, right or left, is the Head directed? To ascertain this by 
passing the hand within and around the womb would of itself be a 
serious operation ; but we have fortunately a safe and certain means by 
which, under all ordinary conditions, we may at once determine the 
exact relation which the child bears to the uterine walls, and so modify 
our operative manipulations accordingly. The information in question 
is to be derived from a careful examination of the arm which presents. 
Prior, therefore, to any operation which we may find it necessary to 
perform, with a view to the rectification of this faulty presentation, we 
must pull down the arm, and carefully observe it, unless, indeed, our 
examination of the presenting shoulder, and the parts beyond, should 
have sufficed clearly to establish the position of the child. The point to 
be first ascertained is, as to the presenting arm, whether it be right or 
left. This is determined, in the simplest possible way, by the accouch- 
eur placing the palm of his hand against the palm of the child's hand, 
when if the thumbs correspond, so do the hands. For example, if he 
employs, as most people do, the right hand, and finds the thumb of the 
child correspond to his little finger, he knows that it is the left hand, 
while if he finds them thumb to thumb, it is the right. This is a cer- 
tain guide, and one in reference to which there is no possibility of fal- 
lacy; but the information which is thus afforded is but limited, and 
only indicates that we have to deal with one of two possible positions. 
A more careful examination of the hand gives us complete and certain 
information, so that we know exactly where to find the anterior and 
posterior surfaces, and the head and the feet of the child. The following 
rule is all that it is necessary to remember : the hand of the child being 
supine, the Palm corresponds to the abdominal surface, and the Thumb 
points to the Head. Here, however, there is a possible source of error, 
which, if not avoided, \vill inevitably lead to wrong conclusions. For 
a moment's consideration will suffice to show that, if we omit to make 
sure that the hand is supine, we run the risk of its being pronated, 
which, by turning the palm towards the back, and the thumb towards 
the feet, may lead us to form an opinion which is, in every respect, 



346 TRANSVERSE PRESENTATIONS. [CHAP. 

wrong. Before making the observation, therefore, be sure that the 
hand is supinated — when error becomes impossible. 

When the body of the child presents transversely at the brim of the 
pelvis, the labor almost invariably requires at the hands of the accouch- 
eur the assistance of art. Indeed, it may be said that, if the pelvis 
be normal, and the foetus living, mature, and of average size, it is im- 
possible for the woman to be relieved by the unaided efforts of nature. 
The progress, and termination of such a case would probably be as 
follows : After a tedious first stage, in which the dilatation of the os is 
unsatisfactorily effected, the membranes rupture, and the arm descends 
into the pelvis, either primarily, or, when the shoulder originally pre- 
sents, after the labor has made some further advance. When this 
occurs, the pains become much more severe and strong, and with each 
succeeding effort the shoulder is forced down, and wedged into the 
cavity of the pelvis. The head being situated, however, to one side, 
and the breech to the other, progress beyond a certain point is mani- 
festly impossible, so that when the utmost degree of moulding is at- 
tained of which those parts are susceptible, and the base of the wedge 
has entered the pelvis as far as the mechanical conditions will permit, 
no amount of uterine or other propulsive effort can produce the slightest 
effect. Left to nature, and attended with powerful uterine action, such 
a case must ere long involve the life of the child, not less by the great 
and continuous pressure on the neck and other vital parts, than by the 
implication, from the same cause, of the placental circulation. The 
actual degree of the pressure is further shown by the tumefaction of 
the limb which hangs down into the vagina, or protrudes partially from 
the ostium vaginse. The sufferings of the mother are in no way alle- 
viated by the death of the child, but, on the contrary, every minute of 
such fruitless effort renders her position more and more precarious. 
The continued pressure on the soft parts of the parturient canal may 
destroy in this way the vitality of the portions most exposed to its 
influence, when sloughing, more or less extensive, will occur, from the 
effects of which, coupled with the prostration and exhaustion which 
gradually wear out her powers of constitutional endurance, her suffer- 
ings are terminated by death. Or, at any stage of the labor, rupture 
of the uterus may occur, and a similar result will, almost inevitably, 
ensue. 

Under certain circumstances, however, — such as a putrid or imma- 
ture foetus, or a pelvis of unusual size, nature may relieve herself by a 
spontaneous process of delivery. One of these processes is associated 
with the name of Denman. This distinguished obstetrician found that, 
under conditions similar to those above noted, what he termed sponta- 
neous evolution occasionally occurred. In those cases, the shoulder, or 
point of the wedge, did not maintain its position in the pelvis, but 
moved upwards, during the continuance of the pains, towards the brim 
of the pelvis, on that side which the head originally occupied, the head 
itself moving in a corresponding direction in the iliac fossa. This 
ultimately made way for the nates, which descended towards the floor 
of the pelvis, when labor terminated as in a case which had been from 
the first a presentation of the breech. This observation of Denman's 



XX.] 



SPONTANEOUS EVOLUTION. 



347 



was hotly, controverted by some of the most eminent obstetricians of 
the day, with the ultimate result, however, of establishing the correct- 



Fiu. 125. 




Spontaneous expulsion. First stage. 



ness of his views. The controversy, moreover, by directing general 
attention to the phenomena of spontaneous delivery, resulted in a 



Fig. 126. 




Second stage. 



thorough elucidation of the whole subject, from which it transpired 
that there was another process, and one of more frequent occurrence, 



348 



TRANSVERSE PRESENTATIONS. 



[CHAP. 



according to which a similar result ensues. The credit of first describ- 
ing this is generally attributed to Dr. Douglas, of Dublin, who, to 
distinguish it from the process of Denman, called it spontaneous expul- 
sion. The mechanism of this differs essentially from the former, as 
the shoulder, instead of ascending, continues to descend, until it be- 
comes fixed against the subpubic arch, when it is arrested and forms 
a centre, upon which the whole body of the child revolves. It is 
obvious that such a mechanism as this can only be possible under the 
same exceptional conditions which permit of spontaneous evolution. 
For in this case the breech must pass the pelvic brim which is already 
partly occupied with the base of the skull, an occurrence which is 
manifestly impossible if the relative proportion of the parts, maternal 
and foetal, are in accordance with the normal standard. The mode in 

Fig. 127. 




Third stage. 



which the successive stages of the expulsion actually occur is shown in 
the accompanying figures, in which is depicted the manner in which, 
while the child revolves, the thorax, buttocks, and remaining shoulder 
succeed each other in their passage over the distended perineum. All 
being thus born but the head, the delivery of that part may either be 
effected by the natural efforts, or with the assistance of the accoucheur 
in the manner already fully described in the last chapter. The long- 
continued ineffectual efforts of the uterus, resulting in complete atony 
of its muscular structure, may at this stage cause the death of the 
woman by haemorrhage so profuse that all our efforts are powerless to 
arrest it, — an unhappy result which is more likely to occur in those cases 
in which operative assistance has been too long delayed. 

There are, perhaps, no cases occurring in the practice of midwifery 
which call for more tact, judgment, and operative skill, than those 
which are now under consideration. The object of all operative in- 



XX.] OPERATIVE INTERFERENCE. 349 

terference is the rectification of a preternatural presentation, so as to 
place the axis of the child in correspondence with the axis of the uterus, 
and thus permit of delivery in consonance with the mechanical laws 
which govern the normal process. Deliberately to leave the case to 
nature, on the chance of the occurrence of spontaneous evolution or 
expulsion, would be irrational in the extreme. For, although the risk 
of operative procedure must not be under-estimated, we may be quite 
certain that the danger which will accrue from delay is vastly greater, 
inasmuch as the child's life is sacrificed, and that of the mother is 
placed in imminent peril. It is scarcely possible in these days that, 
in this or any other civilized country, a woman would be suffered to 
die undelivered, for sooner or later assistance would be sure to reach 
her. Such assistance, however, there is too good reason to believe, 
may be afforded at a period when the vital powers have already begun 
to flag, when the arm and shoulder are already wedged down in the 
pelvis, and when the life of the child has long been destroyed. All 
these circumstances increase very greatly the gravity of the case, and 
may often lead us to despair as to its ultimate issue ; but, whatever 
the difficulties may be, the educated accoucheur must be prepared to 
cope with them, and to act in every case, even the most desperate, in 
such a manner as may at least give the mother what chance human 
skill can afford her. No one point, therefore, is of such importance as 
this, — that we should recognize the position at the earliest possible 
moment. If we have the good fortune to do so early in the labor, we 
may look upon the case with calm self-reliance, knowing that the issue 
lies in a great measure in our hands. No pressure having at this time 
compromised the life of the infant, w T e hear its heart beating vigorously, 
and we may possibly feel it move ; while the maternal parts have as 
yet been subjected to no mechanical violence. No details are requisite 
to prove that, in the two classes of cases referred to, the prospect of 
success is very different, and we therefore repeat that nothing, in point 
of importance, is to be compared with an early recognition of the case. 
This enables us, moreover, to select the time at which we may act with 
the greatest probability of success. 

The choice thus afforded us must be taken advantage of with dis- 
crimination, and in full view of the facts which have been detailed. 
The responsibility which devolves upon the accoucheur in such a case, 
renders it essential that his services should be at command on any 
emergency, such as the arrival of the moment favorable for operation 
somewhat earlier than he might perhaps have been prepared to expect. 
For, as will presently be made apparent, this period may be of short 
duration, and if it be not taken advantage of, the case may pass very 
rapidly into another category in which the risk to mother and child is 
greatly increased. It is of the first importance, as has already been 
mentioned, that the integrity of the membranes should be preserved as 
long as is possible. Any clumsiness or violence of manipulation during 
the course of an ordinary vaginal examination, may thus, by causing 
the escape of the waters, not only permit of the descent of the abnormal 
presentation, but may, by complete evacuation of the liquor amnii — 
upon the same principle as in pelvic presentations — bring the uterine 



350 TRANSVERSE PRESENTATIONS. [CHAP. 

walls into immediate contact with the surface of the child. This is all 
the more likely to occur if we examine during a pain, so that we should 
carefully avoid examination at this moment, or at least conduct it with 
special caution. The patient is to be confined strictly to the horizontal 
posture, but so long as the child is alive, the os but partially dilated, 
and the presenting part still high, it is better to wait than to attempt 
a forcible dilatation of the os, which would most likely involve a rup- 
ture of the membranes. This is the period, however, at which an 
attempt at rectification may be made with considerable prospect of 
success, if we combine the use of the finger internally with the external 
manipulation of Wigand, according to the method recommended and 
practiced by Dr. Braxton Hicks. After having ascertained the exact 
position of the child, or at least the side to which the head is turned, 
this may be effected by pressing the shoulder upwards from the vagina, 
while the head is pressed down towards the brim of the pelvis, and if 
necessary retained there, by the other hand which is applied to the 
surface of the abdomen. The process effected by this manoeuvre is 
what is termed Cephalic Version. The same result has been success- 
fully attained by Hamilton, Gooch, and others, by manipulation which 
is purely internal, and by Wigand and Martin, by a method in which 
the manipulation is exclusively external, but it is to the distinguished 
obstetrician named above that we owe the combined method. 1 This 
subject will be more fully noticed under the head of Turning in a 
special chapter, so that we shall only mention here such points as are 
incidental to the peculiar case which we are now considering. 

The treatment, according to almost all authorities, which is most 
applicable to transverse presentations, is the operation generally known 
as Turning or Podalic Version, to be afterwards more particularly de- 
scribed. Should this operation be determined upon from the first, the 
condition of the membranes is of even greater importance than before; 
and the state of matters which is most favorable to its successful per- 
formance is to be found when the os is in such a condition, as regards 
dilatation or dilatability, as to permit the passage of the hand, should 
that be necessary, while, as yet, the liquor amnii has not escaped. 
Waiting patiently till full dilatation has been attained, or till rupture 
of the membranes takes place, increases in no way, as we have seen, 
the risks of the case. But, so soon as either event occurs, we at once 
proceed to the operation by introducing the hand, seizing the feet, and 
bringing them towards the os uteri, whence the shoulders will recede — 
under such circumstances at least — without difficulty. The mode pre- 
viously detailed of ascertaining the position of the child by observation 
of its hand must here be practiced if necessary, as the result of an error 
in this respect, or a haphazard introduction of the hand within the 
womb, will greatly increase the risk to the mother which attends the 
operation, even when most skilfully performed. The position of the 
child being ascertained, the palm of the child's hand will indicate the 
abdominal surface, to which the hand of the operator should always be 

1 See Dr. Braxton Hicks's Memoir, " On Combined External and Internal 
Version."— London, 1864. 



XX.] TREATMENT. 351 

directed, while by pushing the hand in the contrary direction to that 
in which the thumb points, the feet will most easily be attained, and 
at a minimum of risk. In this case also, the method of combined 
version is equally applicable as for cephalic version. And it requires 
no argument to show that, if it be practicable thus to effect the object 
in view, an operation which consists in the introduction of one, or at 
most tw r o fingers into the uterine cavity, must involve less risk than 
necessarily attends the ordinary procedure of turning by the feet. 
That it is practicable, we have had several opportunities of demon- 
strating, and it is without any hesitation, therefore, that w T e recommend 
that this method should in the first instance be tried in every case, and 
the more severe operation only in those instances in which the former 
fails. As in cephalic version, it is better to attempt rectification so 
soon as the os has sufficiently dilated to admit the finger, and to permit 
an accurate diagnosis. With the escape of the waters, the mobility of 
the foetus is, for obvious reasons, diminished. 

The following, from Dr. Hicks's published cases, is a striking instance 
of how, even under most unfavorable circumstances, combined version 
may be practiced with perfect success. 

" Mrs. M , admitted into Mary Ward in April, 1861. The antero-posterior 

diameter of pelvic brim measured only two inches and one-eighth, which had 
caused her labor to be accomplished with the greatest difficulty; embryotomy being 
employed on the last occasion, although brought on at the seventh month. Labor 
was induced on 13th April last, in the seventh month of this her fourth pregnancy, 
by puncturing the membranes. Pains came on in about sixty hours, after which 
they continued to increase for twenty-four hours, at intervals of five minutes. The 
os uteri was then about the size of half a crown, still unyielding, scarcely admitting 
two fingers. The liquor amnii still existed in small quantities, draining slowly 
away. The shoulder presented, the head being to the right side, the breech to the 
left, but both approaching the fundus, the child being somewhat doubled on itself. 
As it was of much importance to rectify the presentation before the os dilated, so 
that the presenting part might not be driven lower down, and as the footling pre- 
sentation seemed, with so narrow a brim, and a small soft head, to give the best 
chance for the life of the foetus, I decided on attempting podalic version. The 
patient was put under the influence of chloroform. The left hand was introduced 
into the vagina, with two fingers through the os, and the presenting part pushed in 
the direction of the head, while the right hand pressed down the breech from with- 
out. The foetus did not glide round in the uterus very easily, for it was tightly 
clamped by it, and every movement within or without produced uterine action, con- 
sequently it required a little patience; but by varying the position and direction of 
the outside pressure, the foot was at last drawn into the os by two fingers. The 
chloroform was discontinued, and after about half an hour, slight expulsive pains 
appearing, gentle traction was made upon the child. It was not long before the os 
dilated and the child was brought down during the pains. Some detention of the 
head took place at the brim, in consequence of the very narrow antero-posterior 
diameter, and the child's life was lost. The mother did very well." 

The really difficult cases, and those in regard to which apprehension 
will naturally arise, are those in which we have to act after the shoul- 
der has descended in the pelvis, and when the body of the child is 
tightly embraced by the womb. No attempt should be made under 
any circumstances to replace the hand and arm, should these have pro- 
lapsed ; and it Avill generally be proper, before proceeding to operate, 
to allay the excited irritability of the uterus, which shows a spasmodic 
tendency to contract under the slightest stimulus. Of various means 
at our command, that which is most suitable for this purpose is chloro- 



852 TRANSVERSE PRESENTATIONS. [CHAP. 

form, and if the patient be well brought under its influence, it is won- 
derful to what extent we succeed, in some instances, in relaxing the 
parts, so as to admit of the easy passage of the hand. In every case, 
however, such an operation is attended, as compared with one performed 
at an earlier stage of the labor, with greatly increased risk, the danger 
being in direct proportion to the amount of resistance encountered in 
an attempt to pass the hand. The condition of the bladder and rectum 
should, as a matter of course, be ascertained, and, if necessary, those 
viscera emptied before any attempt is made at rectification. A peculiar 
and special resistance may proceed from the state of the os, which, if 
rigid, may constitute a barrier to the passage of the hand. In this case, 
if the waters have escaped, and the probability of its dilatation within 
a given time is thus a matter of great uncertainty, we must endeavor 
to dilate the os, either by the finger in a manner which will be after- 
wards described, or by means of some such mechanical appliance as 
Barnes's bags, and then proceed in the usual way. We may be sum- 
moned to cases in which, although the wedging of the shoulder is com- 
plete, clear evidence is afforded us of the death of the child. The proof 
of death may consist either in the signs of actual putrefaction, when the 
skin will peel off the presenting part, in the observation of a flaccid and 
pulseless funis, which is not unfrequently prolapsed in these cases, and 
in the absence of foetal pulsation and movement; of which signs the 
first two may be regarded as certain, while the last is to be accepted 
with caution. Our procedure here is to be modified by the fact that 
we have now no longer the interest of the child, but that of the mother 
alone to look to, so that our object simply is to deliver her in such a 
manner as may subject her to the smallest possible risk. We make no 
attempt, therefore, in this case, to turn, but at once reduce the bulk of 
the child by evisceration, or bisect its long axis by decapitation, and 
then proceed to extract it in the manner which may seem safest and 
best. 

In a very few cases, in which the special circumstances favorable to 
such an occurrence are present, it may be obvious that the case is about 
to terminate spontaneously, according to the methods of Douglas or 
Den man. This will be recognized in each case by careful examina- 
tion, — more especially during the pains, — which will enable us to make 
out that the process of revolution is being gradually effected. Delay is, 
under such circumstances, quite proper, more especially when the child 
is dead; in which case, indeed, we might assist the process materially 
by the aid of the crotchet or blunt hook. With reference to the more 
frequent of the two processes, Dr. Douglas says, " If the arm of the 
foetus should be almost entirely protruded, with the shoulder pressing 
on the perineum; if a considerable portion of its thorax be in the hol- 
low of the sacrum, with the axilla low in the pelvis; if, with this dis- 
position, the uterine efforts be still powerful, and if the thorax be forced 
sensibly lower during the pressure of each successive pain, the evolu- 
tion may, with great confidence, be expected." 

Compound or Complicated Presentations. — In addition to the various 
presentations already described, there are many others, of rare, though 
possible occurrence, in which certain parts, anatomically distinct from 



XX.] COMPLICATED PRESENTATIONS. 353 

each other, come together towards the os uteri. Most of these presen- 
tations are varieties, more or less distinct, of transverse presentation ; 
but in some, again, the coincidence of the long axis of the child with 
that of the uterus is maintained. We shall only mention here one or 
two of the many possible compound presentations. When the hand 
and head present together, the mechanism of natural delivery is, of 
course, complicated to the extent of the diameter of the arm. In a 
pelvis of large, or even of ordinary dimensions, there is nothing to 
prevent a satisfactory termination of the labor; but, if the pelvic 
diameters should chance to be ever so little out of proportion, the pres- 
ence of the arm may make all the difference in the world, and suffice 
to jam a head which would probably have passed, under the ordinary 
conditions, with very little more difficulty than usual. Nay, even 
when a hand presents on either side of the head, there is nothing abso- 
lutely to prevent the birth of the child, which has, in fact, been 
observed to pass, under such circumstances, without any marked diffi- 
culty whatever ; so that, in both of these instances, we have to deal 
with conditions very different to those which obtain in cross-births. 
But the chance of delay and protracted suffering is sufficient warrant 
for us, in such cases, to attempt a rectification of these presentations, if 
only this can be effected without incurring the risk of making matters 
worse. What we wish to do is to push the arm upwards, so as to allow 
the head to descend, and alone to occupy the cavity of the pelvis. In 
making such an attempt, however, we must be particularly careful not 
to displace the head ; for, if the result of our interference were to be 
that the head was moved from the brim to the iliac fossa, and the 
shoulder thus permitted to descend, we would, in plain language, find 
that we had converted a comparatively favorable presentation into one 
of the most unfavorable which it is possible to conceive. For this rea- 
son, it is generally better to avoid all such attempts until the head has 
entered, or is becoming engaged in the pelvic brim. If we then use 
ordinary caution in our manipulation, we may attempt, without hesi- 
tation, to effect our object by pressing the prolapsed limb steadily up- 
wards ; and, along with this, we should try to retain the head against 
the brim, in such a manner as to prevent the slipping down of the 
arm, until the uterine efforts have caused the head to descend so far 
that this is no longer possible. This latter indication has been success- 
fully fulfilled by combining external with internal manipulation, and 
that in a manner which would encourage us to repeat the manoeuvre 
on any occasion which might occur. 

The Feet and Hands, or one of each may present, and thus consti- 
tute what may be termed an unusual variety of transverse presentation. 
It is a common occurrence, in this variety, to find prolapse of the funis 
as a further complication, and one unfortunately which will add in no 
small degree to our perplexity. As we could scarcely expect in such 
a case to replace both limbs, and as prolapse of the cord of itself in- 
volves very serious danger to the life of the foetus, the very obvious 
and proper procedure is to draw down the inferior extremity, and thus 
complete podalic version. For, if we leave it to nature to select by 
which of the poles of its long diameter the child will descend, it is 

23 



354 



TRANSVERSE PRESENTATIONS, 



[CHAP. 



more than probable that the shoulder will slip down, and the difficul- 
ties of the case will then be very greatly aggravated. Or, as is still more 
likely, the upper and lower limbs will together become wedged into the 
pelvis, and the progress of the labor be as effectually barred as in the 
ordinary transverse position. If the mobility of the foetus within the 
womb is as yet not seriously interfered with, no great difficulty will be 
incurred in the operation, and as the child revolves, its arm will leave 
the vagina and follow the head in its movement towards the fundus. 
But, if the child is so firmly grasped by the womb as to render the 
operation unusually difficult, the woman must be put under the influ- 
ence of chloroform, and a fillet attached by a running noose above the 
ankle (see chap, xxxii), when steady traction upon this, combined 
with pushing up the arm, and with the further aid of external manip- 
ulation, to be afforded by an assistant, will usually effect the version. 
Should the cord have formed one of the elements of the original pres- 
entation, great attention must be paid to it, in order, if possible, that 
it should retreat into the uterine cavity along with the superior ex- 
tremity ; failing which, it should be guided into that part of the pelvis 
where it is least likely to be exposed to injurious pressure. The case, 
otherwise, is to be managed as an ordinary footling presentation, and 
delivery slowly or rapidly effected according to the urgency of the symp- 
toms and the other attendant circumstances. 
Positions more complicated still may be, although rarely, encountered. 



Fig. 128. 




Case of complicated presentation. 



We may have, for example, the Hand and Foot presenting along with 
the Head, or we may have, as in the case which is represented in the 
accompanying engraving, a presentation of the Head, Hand, Foot, and 



XXI.] PROLAPSE OF THE CORD. 355 

Cord. All such cases are to be managed on similar principles by the 
performance of podalic version. In the case in question, the whole of 
the presenting parts were tightly jammed in the pelvis, the child firmly 
embraced by the uterus, and the cord flaccid and pulseless, before it 
was brought under our observation. The woman had previously borne 
several children at the full term. Although greatly exhausted by a 
fruitless labor of many hours' duration, her pulse was of tolerable 
strength ; and it was resolved, after the administration of some stimu- 
lants, at once to proceed to the operation. Version was, however, in 
this instance, effected with extreme difficulty, in the manner above de- 
scribed, by the hand and the fillet. When the child was born, it was 
found to assume, as if from imperfect cadaveric rigidity, the attitude 
which it had occupied within the womb. This was so characteristic 
that a cast was taken, of which the drawing is a tolerably correct rep- 
resentation. Other presentations, in addition to those enumerated, may, 
as we have said, be met with, but the above will suffice to indicate the 
general principles upon which the treatment of all such is to be based. 
All cases of transverse and complicated labor are attended with 
greatly increased risk as regards the child ; and, even under the most 
favorable circumstances, with a considerable addition to the dangers 
which women undergo in childbed. In the former class, it has been 
found that, even including those cases in which the most skilful assist- 
ance has been afforded, more than half of the children perish, while, 
as regards the mother, the deaths are about one in nine. The fatality 
in both depends, in a very great measure, as all experience has shown, 
upon the period or stage of the labor at which assistance is first afforded. 



CHAPTER XXI. 

FUNIS PKESENTATION. 

"PRESENTATION" AND "PROLAPSE" OP THE CORD — RELATION OF THE FUNIS TO 
OTHER PRESENTATIONS — CAUSES OF — SYMPTOMS OF AT VARIOUS STAGES OF 
LABOR— GREAT DANGER TO CHILD — TREATMENT: AT FIRST EXPECTANT: 
AVOID RUPTURE OF THE MEMBRANES: REPOSITION BY THE FINGERS: BY 
MECHANICAL APPLIANCES: VARIOUS REPOSITORIA DESCRIBED: POSTURAL 
METHOD : USE OF THE FORCEPS : TURNING. 

Some writers have, without any obvious advantage, drawn a distinc- 
tion between " presentation " and "prolapse" of the umbilical cord. 
By the former term is implied those cases only in which a portion of 
the cord is situated in the lowest part of the amnionic cavity, so that 
it may be felt from the vagina; either through the inferior portion of 
the uterine wall, or through the membranes, when the finger can be 
passed by the os. Prolapse, again, is restricted to cases in which, after 



356 FUNIS PRESENTATION. [CHAP. 

the rupture of the membranes, a loop of the cord passes into the 
vagina, or even hangs from the vulva, — in both cases preceding that 
portion of the child's body which presents at the os uteri. Such a 
distinction as this is, in so far as classification is concerned, obviously 
useless, seeing the prolapse is merely a more advanced stage, and an 
almost inevitable sequence, of the presentation. 

At the beginning of labor, the funis may present alone at the os, 
and may be felt to occupy the bag of waters before the child has de- 
scended ; or, what is more usual, it descends along with the cranium, 
nates, shoulder, or any other part of the fetus, becoming prolapsed 
only when the membranes give way. Presentation of the cord is an 
occurrence which, although not very frequent, is so hazardous, as re- 
gards the life of the child, that we cannot pass it by without careful 
attention. Considerable discrepancy exists as to the frequency of its 
occurrence, and it has been variously stated by competent and expe- 
rienced observers at from 1 in 37 to 1 in 382. There can be little 
doubt that it often occurs without its being recognized, — in those cases 
chiefly in which the loop is small, and the prolapse consequently 
trifling. This may, in some measure, seem to account for the discrep- 
ancy alluded to; but we may confidently accept of the statistics care- 
fully compiled by Dr. Churchill, — which, on a total of 90,983, give 
one case of funis presentation in 282, — as indicating, approximately at 
least, the state of the case. It is in cranial presentations that prolapse 
of the cord most frequently occurs, — a fact which depends wholly upon 
the great preponderance of these as compared with the other presenta- 
tions. Considered, however, relatively to transverse, breech, and the 
rarer presentations, we find that it is most frequent with the shoulder, 
then with the breech, and, in point of fact, is more likely to occur in 
any other presentation (relatively to its actual frequency) than in 
cranial cases, where the ball-valve formed by the head is, as we shall 
show, less likely than any other part to admit of the descent of the 
coil. Scanzoni brings out the following as the result of his experience: 

Funis presenting once in 304 cranial cases. 
" " " 32 face cases. 

" " " 21 presentations of pelvic extremity. 

" " " 12 transverse presentations. 

The Causes of funis presentation vary according to the presentation 
of the child, and are also influenced by other circumstances. Among 
the predisposing causes, an unusual quantity of liquor amnii is a con- 
dition which, by separating the uterine walls from the surface of the 
foetus, must certainly encourage the displacement in question ; and it is 
mentioned by Scanzoni that, in more than a third of the cases observed 
by him, an unusual quantity of liquor amnii existed. Probably the 
larger the quantity the more likely would be the descent of the cord ; 
so that in cases of Dropsy of the Amnion we might anticipate the 
probability of such a displacement. In the case of a cord of unusual 
length, the conditions are also such as singularly to favor its gravita- 
tion downwards, either prior to the rupture of the membranes, or during 
the escape of the waters, when the loop suddenly slips down along with 
the gush of fluid. In cases where the placenta is inserted near the os, 



XXI.] CAUSES. 357 

and the cord lies, consequently, in its immediate vicinity, the danger 
of prolapse must manifestly be increased, and will, on the contrary, be 
reduced, the further the site of the placenta is from the lower segment 
of the womb. It is doubtful whether a pelvis of unusually large size 
favors, as some have supposed, the descent of the cord ; in fact, we are 
inclined to believe, that so far from this being the case, the unusual 
depth in the pelvis of the presenting part, in these cases, is more likely 
to prevent the accident, by a firmer contact than usual with the inferior 
part of the uterine cavity. But it is otherwise with a narrow pelvis, 
and more especially in such instances as show marked contraction at 
the brim. In these, the descent of the presenting part, and the occu- 
pancy by it of the inferior part of the womb, are mechanically hindered, 
to such an extent that the cord is either forced down by the uterine 
contractions into the bag of waters, or, upon the escape of these, is 
carried past the arrested head by the impulse of the momentary torrent. 
Cases of this kind have been recorded by Mr. Roberton, of Manchester, 
who has paid particular attention to the subject. 

There is, probably, no cause which acts more decidedly in producing 
this unfortunate situation of the cord than the presentation of the child. 
The more thoroughly the lower region of the womb is occupied by the 
corresponding portion of the child, the less likely is prolapse to occur; 
and we find, therefore, that the less effectively this condition is main- 
tained, there is, in direct proportion, increased danger to the cord. In 
the case of the cranial positions, a very superficial observation of the 
facts of the case will suffice to show how admirably adapted these are 
to the mechanical prevention of the displacement in question. It is 
true, indeed, that it is not the head which, in the first stage of labor, 
presses during a pain upon the os, and it might be assumed, as by no 
means improbable, that the cord should slip down into the interval 
between the membranes and the head. But a more close attention to 
the mechanism of a labor-pain, — which has been fully described in a 
previous chapter, — shows that nature, apparently, provides against such 
a movement on the part of the cord, by commencing the contraction in 
the cervix, from whence it passes upwards, and thus, by a sort of inverted 
peristaltic action, maintains the relative position of the parts, which is 
only likely to be disturbed, under such peculiar circumstances, as have 
been above detailed. So soon as rupture of the membranes permits of 
the immediate application of the head to the circumference of the os, 
the same action, beginning in the sphincter fibres of the cervix, and 
exercised equally upon the spheroidal cranium, still more effectually 
prevents displacement. 

It is widely different in the other presentations of the child, which 
we may here consider together. In the case of the face, the conditions 
approach more closely to those of cranial presentations than to any 
other; and we thus find, as we might have anticipated, in the table 
quoted above from Scanzoni, that these are, next to the cranial posi- 
tions, the most favorable. As regards presentation of the nates, we 
have here also a rounded mass, occupying the lower segment of the 
uterus, in a manner which in most cases is sufficient to maintain the 
position of the cord. That its descent occurs in a much larger relative 



358 FUNIS PRESENTATION. [CHAP. 

proportion of cases than in cranial positions, is to be accounted for by 
various circumstances. We cannot fail to observe, in the first place, 
that there is not the same regularity in the circumference of the pre- 
senting breech as in the case of the head. There are thus, necessarily, 
various points at which the contact between the uterus and the present- 
ing mass is comparatively insufficient, so that the cord may easily glide 
down at those points where the resistance is least. We can easily con- 
ceive it possible that, in this manner, a loop of the cord may pass down 
over the genitals in the interval between the nates, and make its appear- 
ance in the vagina, or externally. Should the presentation be one of 
the knees or feet, the conditions favorable to a descent of the cord are 
even more exaggerated. It is in transverse presentations, however, 
that the cord most frequently descends along with, or in advance of, 
the presenting part. There is, in this case, but little to prevent the 
displacement in question; and neither the shoulder nor the arm can be 
looked upon as, in any sense, the mechanical equivalent of the cranium. 
And what makes matters worse, in the case of cross birth, is the prox- 
imity, in every case, of the umbilicus to the os uteri, which must still 
further multiply the conditions favorable to displacement. But, of all 
possible cases, those in which prolapse or presentation of the funis is 
most likely to occur are what have been described in the preceding 
chapter as complicated presentations, — such as hand and head; hand 
and foot; head, hand, and foot; and the like, — in which the conditions 
favoring prolapse reach their maximum. 

Sudden rupture of the membranes, with the accompanying gush of 
waters, has been placed by some in the first rank as a determining 
cause of prolapse of the funis. This is claiming for the phenomenon 
in question too important a position. No one can deny that "pro- 
lapse" of the cord usually takes place at this moment, but the deter- 
mining cause of the displacement has, probably, in almost all these 
cases, been previously in operation, and has already induced a descent 
of the cord as fir as, prior to the moment of rupture, is possible. It 
may, no doubt, happen that, under special circumstances, such as 
abundance of the liquor amnii, a loop of the cord may be carried down 
past the presenting part along with the fluid ; but the usual occur- 
rence, we apprehend, is that the prolapse at the moment of rupture is 
merely a more advanced and complete stage of previous displacement. 

The Symptoms by which this accident is to be recognized vary ac- 
cording as the membranes are intact or ruptured. In the former case, 
the diagnosis is attended with considerable difficulty, inasmuch as we 
can only be guided by the sense of touch through the membranes 
or the thin uterine walls. It is quite possible, at this stage, to mistake 
the inequalities which are presented by the fingers and toes for the 
irregularities due to the twisting of the cord; and, in such cases, the 
only sign upon which we can confidently rely is the observation of the 
umbilical pulse. This is, however, not always easily made out, unless 
we are able to compress the cord between the finger and the presenting 
part of the child. And, even when we do feel pulsation, we must be 
cautious not to mistake the pulsation due to enlarged maternal vessels, 
which are to be distinguished by the synchronism of the latter with 



XXI.] SYMPTOMS. 359 

the radial pulse. It is, then, unequivocal foetal pulsations only which 
are to be accepted under those circumstances as satisfactory evidence of 
the displacement which we are now considering. Whatever doubt 
may exist as to the nature of the case is at once dispelled by rupture of 
the membranes, when the loop of the cord escapes into the vagina, or 
may even pass so far down as to come into sight at the orifice of the 
vagina. But, should the coil be small, or any other circumstance pre- 
vent its prolapse, no difficulty will be met with in perfecting the diag- 
nosis, as the cord may now be felt distinctly, rolling beneath the finger, 
and its pulsation may be ascertained by compressing it directly be- 
tween the fingers ; while the fingers and toes, should these parts have 
given rise to doubt, may, by a similar method of examination, be read- 
ily distinguished. There is one possible, though, perhaps, scarcely 
probable source of error, against which the inexperiened observer must 
here be on his guard. It occasionally happens that, in extensive rup- 
ture of the uterus, a coil of the small intestine passes through the 
aperture into the uterus, and even into the vagina ; and, although the 
presence of the mesentery and the absence of pulsation should in such 
cases obviate the possibility of mistake, the sensation which the bowel 
yields bears such a resemblance to the cord that an opinion might rashly 
be formed, which might lead, in practice, to the most disastrous results. 
Several cases, at least, have been recorded in which this blunder has 
been committed, with the most discreditable and unfortunate issue. 

As regards the mother, there is no risk whatever in a presentation of 
the funis. Experience has, however, shown that, of all possible pres- 
entations, not even excepting trans'verse cases, nothing is more fatal 
to the life of the foetus. Of all cases, and without any reference to the 
fact of assistance being rendered, it is certain that considerably more 
than one-half of the children are lost, which is sufficient to show that 
the treatment or management of the cord, in these cases, during labor, 
is necessarily one of the most important points which can possibly arise 
in the course of practice. What we desire to effect is the protection of 
the cord from such pressure as may arrest the circulation, or, in other 
words, to avert, if it be possible, from the child, the danger of death 
from asphyxia. We have already seen, in reference to presentations of 
the pelvic extremity, that the chief cause of increased mortality in these 
cases is pressure on the cord, and the same remark obviously applies 
with equal force to all cases of transverse or other presentations in 
which podalic version is practiced. But, unless there should be pro- 
lapse, the danger is confined to the later stage of labor, during which 
the cord is subjected to pressure between the head and the pelvic walls. 
If the cord presents originally, the vessels are obviously subjected to 
a more prolonged and continuous pressure, so that the danger is con- 
siderably increased. When, in any case, the labor pains are frequent, 
violent, and of long duration, the chance of the child's life is small, 
unless delivery should be effected with unusual rapidity; but if, on the 
contrary, the pains are moderate, and of short duration, the foetus has 
time to rally, during the intervals, from the effects of the partial 
asphyxia which attends each uterine effort, and the cumulative effect 
of pressure is in a measure avoided. We must, how T ever, even under 



360 FUNIS PRESENTATION. [CHAP. 

the most favorable circumstances, look with serious apprehension, as 
regards the interests of the child, upon all cases of funis presentation, 
and we would do well to make a point in all such instances of inform- 
ing the friends of the patient of the precise danger which we anticipate. 
Many circumstances, other than those already mentioned, modify the 
danger of individual cases, but, in all, the continuousness and the de- 
gree of the pressure are the points upon which the gravity of each par- 
ticular instance depends. If it should so happen, therefore, that the 
cord occupies a position in which it is exposed to comparatively little 
pressure, the chance of the case is greater: and to this Naegele draws 
attention, and points out that when the cord presents with the head in 
the ordinary or first cranial position, the life of the child is much more 
likely to be spared when it lies towards the left sacro-iliac synchon- 
drosis, the point at which it is least likely to be subjected to injurious 
pressure. 

Treatment. — Unless the case is otherwise abnormal, so as to call for 
operative interference in the interests of the mother, we of course leave 
to nature all cases in which we have unequivocal evidence of the death 
of the child. We must, however, be careful in admitting want of pulsa- 
tion in the cord as satisfactory evidence of the death of the foetus. If 
the cord be perfectly flaccid, and is examined continuously, during the 
occurrence of several successive pains, without any pulsation being dis- 
cerned, we can have no doubt that all hope of the child must be aban- 
doned. But, should the examination have been made hurriedly, during 
the occurrence of a pain, we may abandon a remediable case while 
there is yet hope, as it has frequently been observed, in such cases, that 
pulsation is for a long period arrested during the pains, and returns in 
each succeeding interval. As a rule, then, we should examine during 
an interval as well as a pain; and it is only the continuous absence of 
pulsation which is to be admitted as evidence of death. In almost all 
other cases, it is proper for the accoucheur to afford some assistance ; 
and in all, without exception, in which we presume that the child is 
alive, we must watch with constant attention the progress of the labor, 
so as to afford at the proper moment such aid as may be applicable to 
the exigencies of the case. The indications of treatment which are to 
be observed are, either the entire relief of the cord from pressure, or its 
removal to where it will be subjected to the minimum of compressing 
force. While there are special cases in which little or no interference 
is required, or indeed justifiable, these form a very small proportion of 
the whole. The great majority, therefore, are those in which assistance 
of some kind or other is essential, and in many of them the skill and 
perseverance of the operator will be taxed to the utmost. The exact 
circumstances under which the displacement may occur, are of such 
infinite variety, that it were endless to attempt to lay down rules which 
may serve for the guidance of the operator in every case. There is, in 
point of fact, perhaps no contingency in the practice of midwifery in 
which sound judgment and self-reliance are so essential; but we are, 
nevertheless, enabled in the light of the experience of the most distin- 
guished accoucheurs, to lay down certain general principles, upon which 
the management of presentation and prolapse of the funis is to be based. 



XXI.] TREATMENT. 361 

Should the cord be felt through membranes as yet unbroken, or 
through the uterine wall from the vagina, our treatment must be essen- 
tially expectant. It must not be imagined that integrity of the mem- 
branes is, under all circumstances, a guarantee that the cord is safe 
from injurious pressure, but so generally is this the case, that we are 
always bound to assume that upon nothing does the issue of the case 
so much depend as the prolonged retention of the waters. In cases, 
the termination of which is intrusted to the natural efforts, this is, 
indeed, of paramount importance ; and, in all, we look upon the danger 
as imminent only, and not in actual operation, so long as the sac of the 
membranes prevents the prolapse of the cord. Nothing, therefore, can 
be more obvious than that we must exercise the greatest possible cau- 
tion in such manipulations as Ave may deem necessary, with the view 
of subjecting the membranes to no such violence as might cause their 
rupture prematurely. In a word, the preservation of the membranes 
is, in all cases in which we may be fortunate enough to discover the 
cord before their rupture, a point of primary importance. For this 
reason, also, it is far better to leave the presentation in doubt than to 
run any risk of rupture of the sac in our anxiety to be correct in our 
diagnosis ; and, on the same ground, it stands to reason that no attempt 
should be made to replace the cord at this particular stage, or even to 
guide it into those parts of the pelvis at which it will be exposed to 
least pressure. So long as the waters are retained, we may be confident 
that the cord is at least under more favorable conditions than could be 
afforded it by any remedial or operative procedure which we might think 
proper to adopt. In cases, therefore, in which the bag of the waters 
occupies the vagina after the termination of what is usually called the 
first stage, we do not act as we would under ordinary circumstances by 
rupturing the membranes; but, on the contrary, we look upon the 
exceptional persistence of the membranes as of good augury in regard 
to the. child in all cases in which we have already recognized the funis. 
The longer, in fact, the liquor amnii is retained, the shorter will be the 
final stage during which pressure more or less severe must be encoun- 
tered ; and, other things being equal, the less proportionally will be the 
risk to the life of the child. Persistence of the bag of the waters up 
to the moment at which the head is being born is perhaps the case of 
all others in which nature is most likely to secure a happy result. Such 
cases, however — and along with them may be classed instances in which 
the capacity of the pelvis is greater than usual — are not frequently met 
with ; but, when they do occur, we would be quite justified in simply 
watching the progress of the case, and only interfering when the symp- 
toms become more threatening, or the conditions are such as to render 
.prolonged compression of the cord a matter of certainty. 

The cases which are of most usual occurrence in practice, and those, 
too, which are the most favorable in their results, are where the head 
and the cord present together. In cases in which this complicated pres- 
entation has been early recognized, when the membranes are complete 
and the os as yet but little dilated, it has occasionally been observed 
that the presenting cord has passed up out of reach, and the head de- 
scends alone as in an ordinary case. The possibility of such a satis- 



362 FUNIS PRESENTATION. [CHAP. 

factory result would of itself suffice to warrant us in endeavoring, by 
all means, to preserve the integrity of the membranes, but the result 
is not, as will be understood, one upon which we can, in any circum- 
stances depend. It has been asserted upon good authority, however, 
that the conditions which render such an occurrence most likely are a 
small loop of cord, which is situated higher than usual and to one side 
of the os, and when the projecting bag of the membranes is embraced 
by the lower segment of the womb with unusual force. When the 
cord descends along with the head, the risk is not so great to the child 
as in other complicated presentations, of which the cord forms an ele- 
ment; for, although the actual compression is greater, it is of much 
shorter duration than in breech and footling cases, and moreover, the 
danger ceases the moment respiration is rendered possible by the birth 
of the child's head. And, in addition to this, the possibility of suc- 
cessful reposition of the cord is much greater on account of the more 
thorough adaptation of the spheroidal head to the cavity through which 
it has to pass. If, on the other hand, we have to deal with the pelvic 
extremity, the cord, when replaced, is more likely to prolapse anew, and 
in every such instance the chance of prolonged compression is much 
enhanced. No doubt, the actual pressure is, in the first instance, less 
than when it descends along with the head, but we must in such a case 
look forward, not only to a longer continuance of pressure, but, in ad- 
dition, to the same ultimate compression from the head, at a period 
when, from long-continued interruption to the placental circulation, 
and by the operation of other causes, the life of the child is already in 
imminent danger. 

When that stage is reached at which the dilatation of the os is what 
we call complete, the membranes being as yet unruptured, it may oc- 
casionally be a matter of some difficulty to determine upon what prin- 
ciple we are to proceed in the management of the case. We know 
that the danger is greater in first than in subsequent pregnancies, and 
in mature than in premature deliveries; but, beyond this we have 
nothing, in addition to the facts already mentioned, which may guide 
us, further than a correct appreciation of general principles. If, upon 
examination, we find that the cord still pulsates, we may perhaps use 
a little more freedom with the finger, in order to ascertain the proba- 
ble extent of the coil, and the exact nature of the presentation, but, 
with this exception, we must generally content ourselves by watching 
the progress of the case. As the head descends, we should try, if it be 
possible, — and still acting with the greatest caution, — to guide the cord 
towards that sacro-iliac synchondrosis which corresponds to the side of 
the cranium ; and in pelvic presentations it will also be proper to act 
upon the same principle by directing it to that synchondrosis which 
may correspond to the antero-posterior measurement of the breech, 
with the view in each case, of placing the cord at that point of the 
pelvic circumference at which the pressure will probably be least. 

With the rupture of the membranes, the cord will usually prolapse, 
to an extent proportionate to the size of the coil which precedes or ac- 
companies the presenting part. This is the stage which we will gen- 
erally select to attempt the Reposition of the cord. With this object 



XXI.] METHODS OF REPOSITION. 363 

in view, we bring the points of the index and middle fingers to bear 
upon the coil in the interval between the pains, and thus endeavor to 
push it upwards, beyond the presenting part, into the cavity of the 
uterus. The process, when the coil is large, will resemble somewhat 
the procedure applicable to the reduction of a large hernia, by succes- 
sively replacing portions of the cord until the whole has been reduced, 
remembering always that, to be effectual, reduction must be complete, 
and that, if ever so small a portion be left down, pressure may be as 
fatal as if w T e had never attempted the operation. But, with the actual 
reposition of the cord, our difficulties do not cease. The reduction of 
the prolapse may be easy enough, but the real difficulty consists in 
maintaining it in its new position. The finger must, on this account, 
not be hurriedly withdrawn ; on the contrary, we should, by contin- 
uous support, endeavor to retain it within the cavity until the child 
descends somewhat further, and forms, by its presenting part, a plug, 
which renders impossible, from its bulk, the renewed descent of the 
funis. The finger should, with this object, be cautiously removed 
during a pain, when the conditions referred to are, of course, present 
in the highest possible degree, so that, if the operation is successful, the 
labor will now be completed without any further risk than attends an 
ordinary case. For the reasons already stated, success will more fre- 
quently attend our efforts when the head of the child presents, as this 
part more thoroughly fulfils the conditions of an effective plug. Un- 
fortunately, how r ever, in a large proportion of cases, this manoeuvre will 
fail, and the cord will descend again and again, under the impulse of 
the uterine contractions. It was, probably, this unsatisfactory result 
which induced some noted authorities to recommend a more thorough 
method of reposition, by carrying the cord upwards towards the fundus 
of the womb, and endeavoring to suspend it over the limbs of the child, 
or at least to press it completely beyond the head, into the hollow 
formed by the neck. Both of these modes of procedure have been 
repeatedly resorted to, and sometimes with success; but the difficulties 
which attend the operation in each case are such that, in the greater 
number of instances, we will fail utterly in our endeavor to maintain 
the cord in its improved position. 

This acknowledged and, in some instances, insuperable difficulty has 
given rise to much mechanical ingenuity. The object in view is to 
devise an instrument by means of which the funis may safely be re- 
turned to the upper part of the uterus, and, if necessary, retained there. 
Of such as have hitherto been invented, those which are the most sim- 
ple in construction seem to have succeeded best. Michaelis recom- 
mended that a large-sized gum-elastic male catheter should be used, to 
the eye of which the prolapsed cord is attached by a ligature, which is 
to be loosely drawn so as to avoid compression. The stilet is then 
introduced, and the catheter, carrying with it the cord, is steadily 
pushed up in the direction of the fundus, where it may be left, the 
stilet being withdrawn, until the completion of labor. The contri- 
vance of Dr. Roberton is, with a trifling modification, the same as this. 
A simple piece of flat whalebone has been preferred by some, and is as 
simple and as convenient as the other. Perhaps if we w r ere to express 



364 



FUNIS PRESENTATION. 



[CHAP. 



a preference for one form over another, that used by Dr. Braun for 
many years in his Klinik at Vienna might be selected as combining 
simplicity and efficiency in the highest degree. It is made of gutta- 
percha, and is used as is shown in the accompanying figure. It is 
about sixteen inches in length, and has, about two inches from the 
rounded extremity, an aperture of sufficient size 
fig. 129. to allow the passage of a loop of tape or worsted, 

which, after being carried round the cord, is 
brought over the extremity of the instrument, 
and is then pulled so as to grasp the cord firmly 
without subjecting it to dangerous compression. 
The apparatus is then pushed as high as is possi- 
ble in the direction of the fundus uteri, and is 
allowed to remain until the further descent of 
the head in the pelvis presents an effectual bar- 
rier to the prolapse of the cord. When we are 
convinced that this stage has been reached, the 
instrument is to be drawn down with a wrig- 
gling or shaking movement, by which the loop 
passes over the point, and the cord is left behind, 
while the whole apparatus is removed. Kiwisch 
effected the same purpose by fixing the point cut 
from a large catheter upon the extremity of an 
ordinary uterine sound; and we have tried with 
success, an instrument of French construction, 
made of two parallel pieces of whalebone, of 
Braun'srepositorium. which the one slides upon the other, and has a 
sort of hook at the end by means of which the 
cord may be confined or released at will. The principle of the opera- 
tion is in every case the same, and the varieties above mentioned are 
but a few of a large number which practical difficulty has suggested to 
different operators. We cannot, however, depend even upon the best 
of them for reliable and satisfactory results, and, in fact, we find that 
many experienced operators prefer the fingers in all ordinary cases; 
while Tyler Smith informs us that even Michaelis has abandoned his 
ingenious instrument for the use of the finger. Be this as it may, we 
should always try, when the fingers fail, what we can do with a reposi- 
torium, hastily constructed though it may be from such materials as are 
at hand. The success attained by others is ample warrant for perse- 
vering efforts in this direction. 

The Postural Method of treatment has from time to time attracted 
attention during the last thirty years, and is associated chiefly with the 
names of Bloxam, Thomas of New York, and Dyce of Aberdeen. 
When this plan is adopted, the woman is placed upon her elbows and 
knees, so as to raise the pelvis above the level of the fundus uteri, and 
thus to take advantage of the law of gravity. That a certain amount 
of advantage is thus gained may be admitted, and it would appear 
that in practice the results have been in a measure satisfactory. We 
cannot, however, anticipate such results as the supporters of this pro- 
cedure seem to claim for it. The posture in question will doubtless 




XXI.] GENERAL CONSIDERATIONS. 3G5 

tend so far to the gravitation of the cord towards the fundus, but it 
must at the same time cause the head to retreat from the lower segment 
of the uterus, and thus remove what we are accustomed to regard as 
the most effectual barrier to prolapse, for, when a pain comes on, 
gravity is a mere feather-weight in comparison with the power of 
uterine contraction. This may possibly explain why it has not been 
attended with more marked success. We should not hesitate to avail 
ourselves of the postural method in any case of difficulty, and it is 
quite possible that by combining the instrumental with the postural 
method as has been suggested by Dr. Barnes, more favorable results 
may ensue than have hitherto followed the use of either separately. 

So long as vigorous pulsation shows that the life of the child is not 
in immediate danger — and this we should also ascertain by ausculta- 
tion of the foetal heart — we must not cease in our efforts to prevent the 
cord from descending into the pelvis along with the presenting part. 
McClintock and Hardy recommend that the woman should be made to 
lie upon the side opposite to that on which the protrusion has taken 
place. In addition to the means above detailed, the expedients which 
have been devised are endless. Among these may be mentioned 
partial plugging of the uterine orifice, after reposition, by a piece of 
sponge; and the inclosure of the coil of the funis, when unusually 
large, within a bag of some kind, the whole being then returned to the 
uterus and left there. 

It is universally admitted that a certain number of cases do occur in 
which reposition of the cord is a practical impossibility, or would be 
attended with unwarrantable risk to the mother. Of such a nature 
are those cases — by no means of unfrequent occurrence — in which the 
accident is not recognized until the head has already descended far into 
the pelvis. For the management of such conditions no definite rules 
can be given; all will depend upon the peculiar circumstances of each 
individual instance. We must be guided mainly by the following 
general considerations : 

1. We must ascertain whether or not the child lives ; for it must be 
obvious that a negative answer to this question bars all further action 
on our part. When the cord, therefore, is flaccid and pulseless in the 
interval between the pains, and the pulsation of the foetal heart cannot 
be made out, we leave the case absolutely to nature, as we know that 
there is no danger to the mother, and we need no longer act in the 
interests of the child. 

2. No conceivable circumstances will warrant us in subjecting the 
mother to any considerable risk. Practically, in an uncomplicated case, 
she is perfectly safe, so that to endanger her on the mere chance, or 
even probability, of saving her child, would be worse than absurd. It 
is, perhaps, true that there is no operative procedure whatever which is 
not attended with some increase of risk, be it ever so little. But, from 
a moral as well as a practical point of view, we must draw the distinc- 
tion between slight and serious risk, and upon this distinction treat- 
ment will, in many instances, be based. The principle must, however, 
remain a general one, for the gradations between the two extremes are 



366 FUNIS PRESENTATION. [CHAP. 

infinite, and each case should thus be decided on its own merits, and in 
full view of the whole facts. 

3. When reposition is impossible, the simplest and safest mode of 
procedure is to guide the cord, as has already been stated, towards that 
part of the pelvic wall where it is least likely to be subjected to severe 
pressure ; and, of all possible situations, the direction of that sacro-iliac 
synchondrosis which corresponds to the side of the child's head, if it be 
a cranial presentation, is perhaps the most favorable. The pulsations 
of the foetal heart, and those of the funis, must now be carefully watched, 
as representing the condition of the child, and indicating the approach 
of imminent danger ; and upon these observations will chiefly depend 
our future course of action. So long as the pulsations are tolerably 
strong, we are justified in leaving the process to nature ; and in the case 
of a woman who has previously borne children, or in whom the pelvis 
is of larger dimensions than usual, the perilous stage of the labor will 
often be safely passed, and the child born alive; whereas, in the con- 
trary conditions of a prim i para, or a narrow pelvis, the chances of a 
favorable result are comparatively small. 

4. When a failure of the circulation is indicated by the stethoscope 
or the finger, our course of action will be suggested, in a great measure, 
by the stage at which the labor has arrived. If, in an ordinary cranial 
position, the os is fully dilated, and the circumstances are otherwise 
favorable for the operation, we need have no hesitation whatever in 
applying the forceps, and completing the delivery as rapidly as possible. 
In the case of the breech, the fillet or blunt hook may be used, with the 
view of expediting labor; but these, or other operations, are only to be 
attempted when the conditions are generally favorable, and the risk to 
the mother is not great. 

5. The question of turning, in funis presentations, demands, as a 
disputed point in obstetrics, some special attention. In the early part 
of the present century, the operation seems to have been held in pretty 
general esteem, but in more recent times the other and safer modes of 
operative procedure are, when practicable, usually preferred. It must 
not, however, be supposed that the operation so warmly supported by 
Mauriceau is to be, under all circumstances, condemned. There are, 
in the first place, instances in which the operation must be performed 
in the interest of the mother, no less than in that of the child, and in 
respect of which, therefore, there can be no hesitation. Of this nature 
are cases of shoulder presentation and placenta praevia, both of which 
conditions are apt to be complicated with descent of the cord. Here 
we scarcely take the cord into consideration, so clear are the other indi- 
cations ; or, if we do, it is only to admit it as of secondary importance, 
but, at the same time, as an additional circumstance which calls for 
speedy action, so soon as the proper period shall arrive for the perform- 
ance of the operation under the most favorable conditions. But, while 
such cases are clear, it is otherwise when, in a cranial presentation, the 
question of turning offers itself for our consideration in the interests of 
the child alone, other modes of procedure being impracticable. The 
opinion generally entertained is, that under the circumstances to which 
we allude, we are rarely warranted in turning, — a view which we 






XXII.] PREMATURE EXPULSION OF THE OVUM. 367 

believe to be, in the main, correct. That there are exceptional instances, 
however, in which, after other means have failed, we may be justified 
in performing the operation in question, we cannot dispute. There is 
perhaps no one point in regard to presentation of the funis which calls 
for more careful consideration and judicious balancing of the special 
circumstances of individual cases. A capacious pelvis, a yielding and 
moderately dilated os, and other conditions favorable to the operation 
itself, afford strong presumption that turning may be effected without 
any great risk to the mother. The period may not have arrived at 
which the idea of forceps can be entertained, and yet the child is in a 
state of immediate peril, so that the question may simply be: Are we 
to act, or are we to leave the child to its fate? Here, experience, and the 
habitual caution which matured experience engenders, can be the only 
safe guides. We repeat, however, our conviction that cases do occa- 
sionally occur in which we would be justified in turning at once. We 
must not forget, while forming our resolution, that the operation does 
not necessarily, even under the most favorable circumstances, relieve 
the child from danger. For, the operation being performed, there is 
still the critical period of the passage of the head, during which, although 
everything be done which skill can achieve, the child, already enfeebled, 
may succumb from the renewed pressure on the cord. 



CHAPTER XXII. 

PREMATURE EXPULSION OF THE OVUM. 

CLASSIFICATION — ABORTION ; DEFINITION OF — CAUSES : IN GENERAL HEALTH : 
FROM REFLEX IRRITATION : FROM DISEASES OF THE OVUM : FROM ACTION OF 
OXYTOXICS : FROM AFFECTIONS OF NEIGHBORING ORGANS : FROM MECHANICAL 
VIOLENCE — TENDENCY TO REPEATED ABORTION — SYMPTOMS ; AT VARIOUS 
PERIODS — PRECURSORY SYMPTOMS: PAINS: HEMORRHAGE — TO BE DISTIN- 
GUISHED FROM DELAYED MENSTRUATION — SIGNS OF DEATH OF THE FCETUS — 
DISTINCTION TO BE DRAWN BETWEEN "THREATENED" AND "INEVITABLE" 
ABORTION — RETENTION OF THE OVUM — EXPULSION OF THE PLACENTA — TREAT- 
MENT : PREVENTIVE : PREVENTION WHEN ABORTION THREATENED — EXPULSION 
TO BE PROMOTED WHEN INEVITABLE — MANAGEMENT OF HAEMORRHAGE, AND 
OF THE PLACENTA: PLACENTAL FORCEPS — TREATMENT OF A WOMAN AFTER 
ABORTION — PREMATURE LABOR — SPECIAL CAUSES — TREATMENT. 

Although the usual period of utero-gestation is about ten lunar 
months, the ovum may be expelled at any time by premature uterine 
action, the result of the operation of certain causes which we shall have 
to consider. Abortion, in the sense now ordinarily attached to the 
term, is the name which is applied to the occurrence, when it takes 
place before the eighth lunar month ; while Premature Labor occurs 



368 PREMATURE EXPULSION OF THE OVUM. [CHAP. 

during the last three months of gestation. Many writers have confined 
the term "abortion" to the first sixteen weeks, and apply the word 
lliscarriage to the period between that and the twenty-ninth, but it is 
more convenient to adopt the simpler classification, which has the fur- 
ther advantage of allowing the familiar expressions "non-viable" and 
" viable" to be used, as applicable to the foetus, in connection with the 
periods of abortion and premature labor respectively. Miscarriage is 
a term familiar to women, and is used by them as synonymous with 
abortion in the wider sense in which we prefer to use the latter. 

Strictly speaking, Abortion may take place at any moment subse- 
quent to conception. Should the one supervene immediately upon the 
other, or within the first few weeks, no symptom is likely to be mani- 
fested which would attract particular attention, and the blighted ovum 
in such cases might be as impossible of detection as the ovule which is 
thrown off at a menstrual period. If the ordinary catamenial period, 
in a woman previously regular, should pass, her suspicions may be 
aroused ; but, if a discharge manifests itself in a few days thereafter, it 
is assumed that the period has been delayed, and this may be held fur- 
ther to account for the increase in the quantity, and of the pain which 
accompanies it, as compared with the symptoms attendant upon the 
ordinary menstrual flux. In point of fact, it is rare that the abortions 
of the first three or four weeks from the assumed date of conception 
attract such attention as to be brought under the notice of the medical 
attendant. Even during the course of the second month, the symptoms, 
although more distinct, may be overlooked ; and the woman who is 
seized with considerable discharge, and uterine pains of a periodic 
character in the seventh or eighth week, may be quite unaware that 
one of the clots which have been expelled contains the immature ovum. 
To the earliest abortions, the ancients gave the name of Effluxion. 
When it is said, therefore, that abortion occurs most frequently from 
the eighth to the twelfth week, we assume that the earlier abortions 
are not taken into consideration, for in truth we have no means whereby 
the number of the latter may be even approximately computed. 

The liability to abortion is undoubtedly greater in the early months 
of pregnancy, when the union between the chorion and the decidua is 
of a lax character, so as to admit readily of haemorrhage into the space 
between them, with the result of cutting off the temporary communica- 
tion which exists between the mother and child before the formation of 
the placenta. Fortunately, however, the earliest and most frequent 
abortions are not attended with much risk, as the ovum usually escapes 
entire ; and the haemorrhage which accompanies them, and which pro- 
ceeds from the vessels of the decidua, is rarely such in extent as to 
cause any great alarm. In the latter part of the abortion period, — the 
sixth and seventh lunar months, — the symptoms manifested and treat- 
ment required are so analogous to what obtains at the full time, that 
few special directions are necessary for their proper management. It 
is quite otherwise, however, in regard to abortions which occur in the 
middle period, — say from the tenth to the eighteenth or nineteenth 
week. In these cases we have special danger to dread, and, if possible, 
to avert, which separate this from any other period of abortion. These 



XXII.] CAUSES. 369 

dangers are dependent upon special conditions which it is necessary 
carefully to observe and to understand, and the most important of them 
is the alteration in the vascular relations between the maternal and 
foetal systems, connected with the formation of the placenta. 

The Causes of abortion must, before we go further, engage our atten- 
tion. These are very numerous, and, being both general and local, 
may act in a very variable manner in inducing the premature action of 
the uterine fibres upon which the expulsion depends. Many obvious 
causes are to be traced to the general health or temperament of the 
mother. In so far as the familiar affections which so frequently attend 
early pregnancy are concerned, — such as sickness, faintness, salivation, 
and the like, — and which, when extreme, are considered among the 
diseases of pregnancy, it has always been observed that these are very 
rarely the cause of abortion. The most common of all, — sickness, — 
is, even in the worst cases, little liable to be followed by premature ex- 
pulsion. " It is," as Dewees says, " a remark as familiar as it is well 
grounded, that very sick women rarely miscarry;" aud when we see, in 
some instances strong and apparently plethoric women miscarry, who 
have not been sick, we may feel inclined to share the general impression 
that sickness is a safeguard, and probably keeps down morbid irrita- 
bility or rigidity of the uterine fibre. With these exceptions, however, 
it may be assumed that whatever deteriorates the general health of the 
mother is apt to produce abortion, or, at least, to place the woman in 
such a condition that she is more susceptible to the influence of other 
causes which may then come into play. Any serious disease, whether 
acute or chronic, may be the direct cause; and the general symptoms 
which accompany the original disease may be greatly aggravated by 
the occurrence in question. Many febrile disorders are extremely liable 
to lead to abortion, more especially small-pox and scarlatina; and in 
too many of these cases there is a fatal issue. Of chronic diseases, 
none, perhaps, exercise a more marked influence than syphilis, which 
actually seems to poison the ovum, and is certainly associated, in many 
instances, with various forms of disease and degeneration, of which it 
is the seat. But it is not from the mother alone that such influences 
proceed ; for the ovum may be infected by the poisoned spermatic fluid 
of the male; and, in some cases stranger still, it would appear as if the 
woman were a mere conductor of the contagious principle — of which 
one of the most familiar instances is that which is narrated of his own 
case by Mauriceau. This distinguished accoucheur tells us that, shortly 
before he was born, his mother had the misfortune to lose the eldest of 
her three sons by small-pox, and that in spite of her condition, as wo- 
men will do, she tended him with constant and tender care. Mau- 
riceau was born the day after his brother's death, and, although his 
mother, neither then nor subsequently, presented the slightest symp- 
toms of the disease, he had on his body at his birth, five or six un- 
doubted variolous pustules. 

Reflex irritation, from a variety of sources, is one of the most fre- 
quent causes of premature expulsion of the ovum. The irritation may 
start from any part of the alimentary canal, and in those instances the 

24 



370 PREMATURE EXPULSION OF THE OVUM. [CHAP. 

nature of the case may be revealed by the existence of dyspepsia, diar- 
rhoea, dysentery, or intestinal worms. In cases of protracted or inju- 
dicious nursing, it may have its origin in the nipple, by irritation of 
the mammary nerves, as was conclusively shown by Dr. Tyler Smith. 
But, besides such distal sources of irritation, reflex action may, un- 
doubtedly, be induced by direct irritation of the vagina, as in plug- 
ging; or by irritation of the uterus itself, as is effected, in fact, by the 
contact of a dead or diseased ovum. Illustrations of this variety of 
case might be indefinitely multiplied. " We may consider," says Tyler 
Smith, " abortion from reflex action as being, in some points of view, 
comparable with spasmodic asthma, or any other exci to-motor disease. 
From certain irritating causes, an excitable condition of the excito- 
motor arcs concerned in parturition is induced. This state of excita- 
bility once produced, slight causes, which would, in healthy subjects, 
produce no disturbance whatever, are sufficient to produce morbid or 
spasmodic parturition. This excitability is not suddenly reached. It 
requires that the nervous arcs, whether mammary, rectal, or other, 
should be irritated for a considerable time, when an excitable, charged, 
or polar state of the uterine nervous system seems to be produced. The 
period preceding a case of reflex abortion 'may be likened to the time 
preceding an epileptic attack." When the reflex irritation has its ori- 
gin in the ovaries there is a tendency to the separation of the ovum at 
what would have been a menstrual period, — a fact which taking the 
identity of the decidua and the mucous membrane as a matter of un- 
doubted certainty, seems to confirm the views of those who hold that 
menstruation involves a periodical discharge of that membrane. This 
particular cause seems, moreover, to occur, for the most part, in those 
who have suffered, before impregnation, from some form of dysmen- 
orrhea. 

Abortion is clearly associated in some cases with certain diseases of 
the ovum. These have already been incidentally referred to in speak- 
ing of the diseases to which the embryo is subject. That fatty degen- 
eration of the chorion and placenta has a marked and decided influence, 
seems at least to have been established beyond doubt in the admirable 
researches of Dr. Barnes. The particular variety of this degeneration 
which exercises the most undoubted influence upon the ovum in in- 
ducing premature expulsion consists in a metamorphosis of portions of 
the maternal and fetal structures of the placenta. This may occur at 
any period of intra-uterine life, and the appearances presented by the 
cells of the decidua in the healthy and degenerated placenta are indi- 
cated in the figure, where the two are similarly magnified and shown 
in juxtaposition. It is unnecessary to follow the minute and interest- 
ing series of changes which have been traced in reference to this form 
of degeneration. It seems, however, to be clearly proved that it is 
frequently induced by constitutional syphilis. The decidua, placenta, 
and other parts of the ovum are, like all other vital textures, liable to 
congestive and inflammatory affections, which may arrest the vitality 
of the foetus, either by inducing some of the various forms of degener- 
ation, or by causing sanguineous effusion into the tissue of the placenta, 



XXII.] 



CAUSES. 



371 




Cells of fatty and healthy decidua. 



which has occasionally been found to contain purulent deposits. When 
the blood effused is considerable in quantity, it constitutes what Cru- 
veilhier has described un- 
der the name of Apoplexy 
of the Placenta, which by 
interrupting the circula- 
tion, may cause death of 
the foetus, and, conse- 
quently, inevitable abor- 
tion, although the foetus 
may be retained in utero 
for a considerable time, 
while the degenerated 
structures of the ovum 
undergo further change. 
Any of the numerous dis- 
eases to which the foetus 
is liable may cause its 
death, and it is believed 
that twisting or knotting 
of the cord, either upon 

itself or round the neck of the child, may have a similar result. Like 
the placenta, and other tissues of the ovum, the cord too is subject to 
special diseases, in the course of which its function is destroyed. Be- 
sides this, the facts stated by Mauriceau, Stein, and others, seem to 
prove that the cord, when too short, may be so dragged upon as to 
endanger its integrity. 

Among the causes of abortion we must not omit to mention those 
agents to which the name of Oxytocics has been given. The more 
familiar of them are the ergot of rye, borax, and savin, which, with 
some others, exercise an undoubted effect upon the muscular tissue of 
the uterus. The nature of their action is not thoroughly understood ; 
but it is certain that ergot, and probable that the others, exercise a 
marked influence upon the spinal cord. Through this channel, then, 
we may infer that the oxytocic influence passes, which incites the uterus 
to contraction. The uterus is, however, not nearly so obnoxious to the 
action of these agents as when the organ is fully distended, either at the 
end of pregnancy, or from any other cause. A similar action is pro- 
duced by carbonic acid, as has been abundantly proved by the records 
of cases of accidental or intentional poisoning. A precisely similar 
effect follows the retention of carbonic acid in the blood in asphyxia — 
a condition under which expulsion of the ovum has very frequently 
been found to occur. Of the five hundred Arabs who were suffocated 
in the caves of Dahra, in 1845 — as is said, by the orders of the Due de 
Malakoff — a considerable proportion were women ; and of these many 
who were pregnant were found to have aborted ; and other instances of 
a similar nature have also been recorded. The same fact has been 
proved experimentally by the researches of Dr. Brown-S£quard, who 
further believes, as we have already stated, that the oxytocic action of 
carbonic acid is the determining cause of labor at the full term, excit- 



372 PREMATURE EXPULSION OF THE OVUM. [CHAP. 

ing, by the direct contact of venous blood, the irritable uterine fibre to 
contract. Emotional causes, such as joy, grief, anger, and the like, may 
produce an effect precisely similar. In some cases of auto de fe, and 
other barbarous acts in which the victim perished at the stake, abortion 
has also taken place, partly, as is probable, the result of fear, and partly 
by the action of asphyxia. 

Certain affections of neighboring organs may produce the premature 
expulsion of the ovum. In many of these cases, it would seem as if 
the cause was a purely mechanical one. Tumors, adhesions which 
bind down organs that ought naturally to rise with the uterus, and 
anything, in fact, which may mechanically hinder the development of 
that organ, may act in the same way. Displacement of the uterus 
itself may act in the same manner ; and we have known cases of uterine 
retroversion, for example, in which abortion had occurred several times, 
and in which an ovum only reached maturity after the displacement 
upon which the abortion depended had been cured by appropriate 
treatment. 

Premature expulsion of the ovum may also follow the occurrence of 
accidents or mechanical violence of any kind, such as falls and blows, 
and these cases are important, as the symptoms which accompany abor- 
tion differ in them from the other cases previously detailed. Such 
causes may act in either of two ways : by an effect produced on the 
organs or tissues of the mother, or by injury to the foetus which may 
cause its death. It has been denied by some authors that the latter is 
a possible cause, so admirably has nature provided against the effects 
of accident and shock. We do not speak now, of course, of extreme 
violence, but of such only as may afterwards operate as a cause of 
abortion. The following case, given by Cazeaux, is conclusive as to 
this: " A young woman, six months pregnant, while groping in the 
dark in her room, struck the abdomen violently against a table. 
During the night the movements of the child became suddenly very 
violent, then diminished, and the following day were no longer felt. 
Two days afterwards she was delivered of a dead child, which pre- 
sented on the back an ecchymosis as large as the palm of the hand." 
Burdach gives the case of a woman who, in the sixth month of preg- 
nancy, had received a blow on the lower part of the belly, of sufficient 
violence to fracture the forearm and the leg. The child was carried 
to the full time, and the fracture was found at birth to have united at 
an angle. The effect of such accidents as tell directly on the maternal 
parts is more obvious. Nothing, however, is more astonishing than 
the amount of violence which women may suffer with perfect impunity, 
in so far as pregnancy is concerned. Falls from windows, giving rise 
to severe contusions and fracture of the limbs, have repeatedly occurred 
to women who were pregnant, without causing abortion. The late Dr. 
Pagan used to tell of an instance in which his coachman drove right 
over a woman who was in the eighth month of pregnancy, inflicting 
upon her very serious injuries. His master, thinking that premature 
delivery must of necessity follow, caused frequent inquiries to be made, 
and found ultimately that the pregnancy was in no way disturbed, and 
that the woman was delivered of a healthy child at the full time. The 



XXII.] SYMPTOMS. 373 

slowness with which the uterus responds, in many instances, even to 
considerable irritation, is familiar to those who have had occasion to 
induce premature labor ; and the fatal result, in cases of criminal abor- 
tion, is, no doubt, mainly due to the amount of violence which is resorted 
to, in the hope of exciting the contractions which milder measures have 
failed to induce. 

A disposition which is exactly the opposite of this exists in some 
women, who, so to speak, abort upon the slightest provocation. That 
in many of those cases of habitual abortion, there is some anatomical 
or physiological cause upon which the phenomenon depends is more 
than probable ; and in all those instances in which there exists a me- 
chanical impediment of any kind, it may follow impregnation periodi- 
cally, almost as a matter of course. But, putting such aside for the 
moment, there are other, and by no means rare, instances in which we 
can only account for the repeated abortions by supposing that the 
uterus has contracted an inveterate habit. It is, perhaps, one of the 
most familiar observations in obstetrical practice, that a woman who 
has previously aborted is much more liable to a repetition of the acci- 
dent than one who has never been pregnant, or who, if previously 
pregnant, has carried her children to the full term. And, when abor- 
tion has occurred in several successive pregnancies, we look upon a 
recurrence of that condition with some apprehension. In such cases, 
it is very generally observed that the tendency to separation of the 
ovum is greatest at a certain period of pregnancy ; and every accouch- 
eur of any experience can recall cases in which successive ova were 
thrown off at exactly the same age, as calculated from the presumed 
period of conception. It would thus seem as if, in those cases in which 
no obvious cause can be detected, there was some perverted condition 
of the uterine fibre, as regards irritability, which prevented dilatation 
of the viscus beyond a certain point, analogous to what obtains in 
morbid irritability of the bladder, when the desire to micturate occurs 
long before even moderate distension has taken place. And in the 
latter case, too, habit has something to do with it, and resisting the call 
has sometimes, at least, a beneficial effect. In the case of the womb, 
however, voluntary resistance has no effect, and so the act goes on re- 
peating itself if unchecked. 

If those above detailed embrace the chief, they are far from repre- 
senting all the causes which may possibly lead to premature expulsion. 
This would require a special treatise. Enough has, however, been said 
to enable us to apply the principles of treatment, which, without a 
knowledge of the etiology of this subject, w T e could by no possibility 
attain. 

Symptoms. — These vary somewhat according to the cause and the 
period of pregnancy. One of the most constant symptoms of all cases 
is pain, but in some instances the expulsion seems to be accompanied 
with little pain or even discomfort. In very early abortions, — the 
" Effluxio" of the ancient writers, — the pain may be no more than that 
which attends an ordinary menstrual period. The seat of the pain is 
usually the lumbar, sacral, and hypogastric regions, but it may extend 
to the groins and down the thighs. A trifling increase in the amount 



374 PREMATURE EXPULSION OF THE OVUM. [CHAP. 

of the catamenial pain, and the presence of some solid masses along 
with the discharge, may be the only symptoms which attract attention, 
and are not unnaturally mistaken for those which accompany a delayed 
menstrual period, when the ordinary functions of the parts are shortly 
resumed as before. At a more advanced period the symptoms are, as 
might be expected, more marked. The occurrence is then frequently 
ushered in by a rigor, followed by an increase of temperature, some 
increase in the frequency of the pulse, thirst, and sometimes nausea, 
even when this has not been present before. Other and more vague 
symptoms, such as palpitation, cold extremities, dimness of vision, and 
dark rings surrounding the eyes, have also been noticed. A cold un- 
easy feeling about the pubes, with more or less of weight in the same 
region, according to the size of the embryo — which may also be ex- 
perienced in the coxal region — is looked upon, and with justice, as a 
characteristic and important sign. Lumbar pain and vesical tenesmus 
are also of frequent occurrence. If they should have been present, 
there is a cessation of what are recognized as the breeding symptoms : 
morning sickness is no longer complained of, and the mammae usually 
become flaccid, although the pain in these glands is sometimes con- 
siderably increased. 

Those symptoms are in their nature precursory, but are soon suc- 
ceeded by increase in the lumbar pain, which becomes periodic, and 
extends to the hypogastric region. If the fundus can be distinguished 
behind the pubes, it will now be felt to contract, indicating the com- 
mencement of uterine expulsive effort. If a discharge of a hemor- 
rhagic nature has not previously taken place, that symptom will now 
be observed ; the amount of the discharge varying very greatly — 
depending, no doubt, on the extent to which the ovum has become 
separated from its attachments. An examination should now be made 
by the finger ; but this must be conducted with great caution, as any 
roughness of manipulation might make matters worse, by exciting the 
uterus to more energetic action, or, possibly, by rupturing the thin sac 
which contains the liquor amnii and the embryo. The os and cervix 
will be felt to be softened to an extent commensurate with the period 
at which the pregnancy is presumed to have arrived ; and, in addition, 
the os will be found more or less patent. 

In the earlier periods of pregnancy, we may have some little difficulty 
in making out whether the woman is pregnant or not. In many cases, 
therefore — in unmarried women for example — we must be very cautious 
in expressing an opinion on this point, however suspicious the symptoms 
may appear to be. According to Madame Lachapelle, the following 
points are of importance in establishing a distinction between the two. 
If the case be one of abortion, the os is more or less open ; haemorrhage 
usually precedes the pains, and gives them no relief; but, on the con- 
trary, they become more severe as the case advances. If, on the other 
hand, the case be one of delayed menstruation, the os is nearly closed, 
or is at most very slightly opened : the pains precede the haemorrhage, 
and are diminished upon its occurrence, or may entirely cease when it 
is thoroughly established. These points are, no doubt, of importance, 
but are to be received in evidence with caution. Certain other rules 



XXII.] SYMPTOMS. 375 

are given with the view of enabling us to distinguish between a clot 
and an ovum in a digital examination at the os uteri, but these are of 
little if any practical importance, seeing that both a clot and the ovum 
may, and often do, present simultaneously. 

As the case progresses, and the rhythmical uterine contractions con- 
tinue and increase in energy, the os dilates still further. For reasons 
which are obvious, the dilatation is often very tedious. At the period 
of pregnancy at which abortion occurs, the cavity of the cervix is, as 
will be remembered, not at all invaded by the process of distension to 
which the cavity of the uterus proper is subjected. Naturally, there- 
fore, its distension by the uterine efforts is effected under circumstances 
of comparative mechanical disadvantage. The conditions at least are 
widely different from the termination of the period of gestation, when 
the circumference of the external os is the only point against which the 
uterine efforts are directed; and, although the dimensions of the body 
which is to pass are to be taken into consideration, the wonder is that 
the difficulty of dilatation is not more universally marked. The rup- 
ture of the membranes is somewhat irregular in its occurrence, but if 
these remain intact, they will often be found to protrude in a manner 
similar to what obtains in labor at a more advanced period. In the 
course of the first few weeks, the ovum is generally expelled entire, 
which, indeed, is a most favorable occurrence, and the cause of the fact 
that the abortions of that period are comparatively free from danger to 
the mother. When the membranes rupture, the embryo is expelled, 
and may be followed at a variable interval by the secundines. Or the 
latter may be retained for a longer period, to give rise to symptoms 
and difficulties which will require for their management all the skill 
and judgment which we have at our command. 

As a general rule, the death of the foetus precedes the uterine con- 
tractions which cause its expulsion. In other cases, again, the foetus 
is born in such a condition as would seem to indicate that it had only 
perished while undergoing the process of expulsion ; and, in a third 
class, chiefly the result of accidents, it is expelled alive, and may move 
briskly for a few hours after its birth. 

It not unfrequently occurs that the symptoms which indicate the 
death of the foetus are separated by a considerable interval from those 
which accompany the expulsive phenomena. When the former, the 
more important of which have already been detailed, have been distinct 
and unequivocal, the sequela?, or external manifestations of abortion, 
are always to be looked for, usually after an interval of some days. 
When the woman has received an injury, or has otherwise been sub- 
jected to violence, the ovum may, if it be a very early abortion, be 
expelled almost immediately. If, however, it has attained any size, a 
certain interval must elapse, when, upon the death of the child, a simi- 
lar but more gradual result will ensue, the mechanism of the expulsion 
being essentially the same as in the other case. It is in the cases in 
which the cause has been one rapid in its operation that the child is 
most frequently born alive. Whatever the cause may originally have 
been, if it acts by first destroying the life of the foetus, the latter plays 
the part of a foreign body, and, as such, excites the uterus to contract. 



376 PREMATURE EXPULSION OF THE OVUM. [CHAP. 

"The living foetus," says Rigby, "obeys the law of organic life; the 
dead foetus those of gravity. When once the child has ceased to exist, 
it acts like any other mass of inanimate matter;" and this too is the 
reason why the feeling of weight is so frequent, and upon the whole so 
reliable a symptom in the more advanced periods at which abortion 
may occur. 

The symptoms of abortion call in every case for careful observation 
and attentive consideration. The most important practical point which 
may arise is the following : No doubt, we shall suppose, is entertained 
as to the fact of pregnancy, while the symptoms are clearly those of 
abortion. But are the symptoms those of threatened abortion only, or 
do they imply that the loss of the ovum is inevitable? In the former 
case, we must do all we can to avert the expulsion; in the latter, we 
do all in our power to promote it; hence the importance, nay, the ne- 
cessity of recognizing the special symptoms which enable us to distin- 
guish the one class of cases from the other. If we are called to a case 
of abortion at the onset of the symptoms, we may assume that the loss 
of the ovum is seldom inevitable unless it is dead. Nothing, there- 
fore, short of clear evidence of the death of the foetus will warrant you 
in abandoning all effort to save it. The danger depends for obvious 
reasons upon the extent to which separation has taken place between 
the ovum and the u'erus. Whether the ruptured vessels are decidual 
or placental, the maternal vascular supply for the nutrition and respi- 
ration of the foetus is more or less restricted by the rupture of the con- 
necting vessels. No symptom, therefore, is of greater importance, than 
the amount of haemorrhage which has occurred, as this may be held to 
indicate with tolerable certainly the extent of the separation and rup- 
ture of the tissues from which the blood flows. The quantity of the dis- 
charge is much more important than its duration, so that, whereas in the 
former case, we despair of the issue, or at least look forward with much 
apprehension, in the latter we will often meet with instances in which 
a moderate or trifling amount of discharge may persist for many days 
without the slightest effect being produced in arrestment of the process 
of gestation. Profuse haemorrhage, then, recurring, at short intervals, 
and accompanied with pallor, vomiting, and a tendency to syncope, 
indicates extensive separation of the ovum, and proportionate gravity 
in the nature of the case. 

Uterine contractions may not only be present, but may persist for a 
considerable time ; but we should never on this account alone place the 
case in the "inevitable" category, as the symptoms sometimes subside 
spontaneously, and often under appropriate treatment. Rhythmical 
uterine contraction, however, is always a most alarming sign, and more 
than sufficient to cause anxiety ; but the significance of this as an 
isolated symptom will chiefly depend on the vigor and continuance of 
each successive pain. Of greater importance is the condition of the os. 
If this is agape, with some portion of the ovum already protruding, 
prevention is out of the question. If even we fail to reach any por- 
tion of the ovum, and the os is widely patent, we recognize in that 
fact, evidence which, if not conclusive, is at least presumptive of abor- 
tion ; while, on the contrary, if the os is but slightly dilated, and the 



XXII.] RETAINED PLACENTA. 377 

cavity of the cervix has as yet been but little encroached upon, our 
hopes of a favorable issue are greatly strengthened. 

One of the worst indications possible is in the discharge of the liquor 
amnii, and in fact, when we can be sure that this has taken place, we 
mav abandon all hope of tiding over the emergency. Evidence of 
rupture of the membranes must, however, be cautiously received. The 
assertion of the patient on a point such as this may go for nothing. 
The observations of an intelligent nurse are, of course, of greater value; 
but we must be cautious even then, as the possibility of hydrorrhoea 
and discharges from other sources must be admitted and disposed of 
before we can speak with confidence. If, with discharge of the waters, 
we have a gaping os, profuse haemorrhage, and obliteration of the cer- 
vix uteri, the case may be given up, and our efforts directed into a new 
channel, with the view of expediting the process which, under more 
favorable circumstances, it would have been our duty to oppose. With 
intact membranes, closed os, trifling haemorrhage, and moderate or irreg- 
ular uterine contractions, our prognosis may be favorable, but is to 
be expressed with caution, as graver symptoms may at any moment 
supervene. 

In most cases of abortion, the expulsion of the ovum is slow, and it 
thus happens that the ovum, or a portion of it, is sometimes delayed 
for days in the orifice of the os. In so far as danger from haemorrhage 
is concerned, the death of the foetus some time prior to its expulsion is 
an advantage, as the utero-placental vessels atrophy, and there is thus 
little danger of haemorrhage — less even than in labor at the full time. 
Or, if the supply of blood be continued as before, it is misapplied, and 
results in the morbid development of the parts and the formation of 
a mole. In some cases, again, the death of the ovum is not followed 
by its expulsion, but it is retained for many weeks, or even months. 
At a very early period, the delicate tissues of the embryo are dissolved 
in the liquor amnii, and are said then to form a gummy solution. At 
a later period, it shrivels or dries up like a little mummy, and may 
remain unaltered in this condition during the remainder of its sojourn 
in the womb. In other cases, it assumes the saponaceous and withered 
appearance, without any putrefactive odor, so graphically described by 
Devergie, which is apparently analogous to that variety of putrefactive 
change which the same eminent medical jurist has described under the 
name of adipocire. In these cases, the woman may experience but 
little uneasiness, or may be perfectly unconscious of anything unusual. 
She and her attendants may suppose that the ovum had passed unde- 
tected, until, after a long interval, a mass escapes from the vagina, 
with or without pain, an examination of which at once reveals the 
nature of the case. 

Apart from the danger arising from haemorrhage before abortion, the 
peculiar circumstances which attend the Expulsion of the Placenta are 
of the highest importance, and differ in many essential particulars from 
the corresponding phenomena of labor at the full time. " In all cases, 
the placenta is retained much longer after the expulsion of the child 
in abortion, than in labor at the full time." Thus wrote Burns, and 
his assertion is undoubtedly correct ; but we must here make a distinc- 



378 PREMATURE EXPULSION OF THE OVUM. [CHAP. 

tion between the different epochs of abortion. In the first and second 
month, the placenta being undeveloped, the ovum is generally expelled 
entire, with little risk to the woman. In the course of the fifth and 
sixth month, the mode of expulsion of the foetus does not materially 
differ from what obtains in birth at the full time, except that there is a 
greater tendency to retention of the placenta and its attendant dangers. 
It is to the middle term of the abortion period, therefore, that our 
attention requires more particularly to be directed — say from the 
eighth to the eighteenth week. During this period, the placenta forms 
a close anatomical connection with the uterine tissues and with the 
maternal vascular apparatus, connections which are often to be severed 
only with the greatest difficulty. The uterine contractions suffice, in 
many instances, to burst the ovum and discharge the foetus, and when 
the cord breaks or is tied, uterine action ceases. But, instead of a 
speedy recurrence of the pains, and a natural and unaided expulsion of 
the placenta, the uterus remains quiescent, the os closes, and the pla- 
centa, with the membranes, is retained, sometimes for hours only, but 
often for a much longer period, extending to eight or ten days, or even 
more. The absence of pain, and other symptoms of importance, may 
induce the woman to believe that she is perfectly well, and we may on 
this account have some difficulty in convincing her of the necessity 
which exists for perfect rest. A return of the pains, after a very 
variable interval, marks a renewed attempt on the part of the uterus 
to rid itself of its contents. If a considerable time should have elapsed, 
the os will have closed so firmly that a tedious process, which is con- 
ducted at great mechanical disadvantage, is necessary for its dilatation. 
This process is often attended with alarming haemorrhage, as it is only 
now that the utero-placental vessels are being severed, and this haemor- 
rhage may only cease upon the expulsion or extraction of the placental 
mass. 

Should there be no effort at expulsion, the placenta will usually be- 
come the seat of putrefactive changes, a condition which will be mani- 
fested by the occurrence of a dark and fetid discharge. Under the 
influence of this, the structures may be broken up and discharged 
piecemeal ; but the process is always tedious, and may be accompanied 
by low fever, in consequence of which the woman may become reduced 
to a condition which may excite considerable alarm, and there is of 
course the danger of what fortunately does not often occur in such 
cases, viz., blood poisoning through the uterine veins. A similar con- 
dition, as regards discharge and general symptoms, may also supervene 
in those instances in which the membranes rupture, and the foetus, as 
well as the placenta and membranes, is retained, the access of atmos- 
pheric air in this as in the former case giving rise to putrefactive de- 
composition. It is said that, in some cases, absorption of the placenta 
occurs, and in this way the uterus may get rid of its contents. " In 
cases of twins," says Burns, " after one child is expelled, either alone 
or with its secundines, the discharge sometimes stops, and the woman 
continues pretty well for some hours, or even for a day or two, when a 
repetition of the process takes place, and, if she has been using any 
exertion, there is generally a pretty rapid and profuse discharge. This 



XXII.] PREVENTIVE TREATMENT. 379 

is one reason, amongst many others, for confining women to bed for 
several days after abortion. The second child may, however, be 
retained till the full time." 

There is one other point which is of great value in estimating the 
gravity of the symptoms of what is supposed to be retained placenta 
after abortion. The accoucheur may have had no opportunity before 
this of personally ascertaining the facts of the case, and may therefore 
be grievously misled by the details with which he is furnished. Noth- 
ing is of greater importance in the earlier abortions than that all clots 
and solid matters which may escape should be carefully preserved for 
examination ; but, unfortunately, this is seldom done. We may thus 
be in no small measure perplexed by the doubt whether the imper- 
fectly formed placenta and embryo, or the placenta alone remain be- 
hind. The history which we may receive from the woman or her 
attendants must therefore be cautiously received, as quite circumstantial 
details are sometimes given of the expulsion of the embryo, and yet the 
issue of the case may show that the presumed ovum can have been 
nothing but a clot, the layers of which may have appeared to resemble 
the membranes which inclose the product of conception. Important 
information is almost always to be derived from a careful inspection of 
the discharges, and all clots should be washed and carefully examined 
with a view to the discovery of shreds of membrane, fragments of pla- 
centa, or structures which show, more unequivocally still, the nature 
of the case. 

Treatment. — The treatment of abortion may be arranged under two 
heads : 1st, to prevent it when this is possible ; and 2d, to favor expul- 
sion when this is inevitable, — under which we may include the man- 
agement of the placenta. 

The Prevention of abortion may, as a practical question, be presented 
for our consideration under various forms. In the case of the woman 
who has aborted on several occasions successively, our treatment is, in 
the strictest sense, preventive, and must be commenced long before 
actual symptoms of abortion are manifested. In regard to this par- 
ticular branch of treatment, while there are certain general principles 
upon which the management of all cases must be based, there are, at 
the same time, special considerations, which must not be lost sight of, 
as applicable to individual cases. A careful investigation of the causes 
which may have induced, on former occasions, the premature expulsion 
of the ovum, will sometimes point to the special considerations alluded 
to. There is a great tendency, in those cases of repeated abortion, to 
the separation of the ovum at the same period of gestation. This law 
operates with great force in cases in which there is no cause in the con- 
stitution of the mother, nor disease in the ovum, to which it can be 
attributed ; so that, in some instances, the uterus actually seems, as it 
has often been expressed, to have contracted a habit of periodical abor- 
tion. The general principles then, which guide us have their origin 
in this fact, and the treatment of every case is more or less based upon 
it. The object is, if it be possible, to tide over the period of former 
abortions; and, when this can be successfully effected, the pregnancy 
will often progress, and reach the full time, without the occurrence of 



380 PREMATURE EXPULSION OF THE OVUM. [CHAP. 

a single bad symptom. If we can only succeed in breaking the 
habit, — be the ultimate result of the pregnancy what it may, — we have 
achieved something in the way of success ; and we have known more 
than one instance in which the result of treatment was, in the first 
place, to transfer the period of abortion from the third to the fifth 
month, and on the occasion of the next pregnancy, a repetition of the 
same treatment was attended with the most satisfactory results possible. 

In effecting our object, in the circumstances now under consideration, 
rest must be placed first among the remedial agencies in which we may 
trust. The strictness with which we enjoin rest will depend, in a 
great measure, on the number of previous abortions, and the extent to 
which preventive measures have already been adopted. In the worst, 
or most obstinate cases, nothing will do short of absolute confinement 
to bed, in the recumbent posture. When the woman has aborted but 
once or twice, it is by no means necessary that absolute rest should be 
so strictly enforced; but, in every case, the chief care is to be directed 
to the period at which previous accidents occurred. Something will 
depend on the effect which want of exercise may have on the general 
health, and if any deterioration should be observed in that direction, it 
becomes a matter of consideration, whether we are not doing more 
harm than good by the course we are adopting. And, moreover, there 
are many cases in which the circumstances of the patient render it, for 
her, an impossible matter to abstain from all physical exertion ; and 
there are other cases, again, in which we have to take into considera- 
tion the amount of energy which exists in the temperament of the 
patient, as it is clear that the woman who leads a life of irrepressible 
energy will require more restraint than one who is languid and disin- 
clined to exertion. There are other causes which, no less than physical 
exertion, must be avoided, as far as is practicable. Among them are 
emotional causes, and any local irritation which might, by any possi- 
bility, act reflexly in the direction of the uterus. Irritations of the 
skin, bladder, or alimentary canal, are of this nature, and even such 
distal irritation as toothache has been known to act in a similar man- 
ner. A careful inquiry into the circumstances which attended former 
abortions should always be made; and, if it is found that diarrhoea, 
vesical irritation, or any similar affection, was a prominent symptom, 
as these sometimes are, it will be proper narrowly to watch, and if 
necessary to rectify, the function which may thus have been disturbed. 
Separation a tlioro is in most cases proper, and in some indispensable; 
and, if necessary, the patient should be cautioned against the effects of 
tight lacing. 

In women who are constitutionally weak, or apparently cachectic, a 
tonic treatment is, in addition to the precautions just mentioned, held 
to be proper. Some Spas, chiefly chalybeate, enjoy a certain reputa- 
tion in such cases, and tepid or cold sea-bathing, both before and after 
conception, has been strongly recommended by Mr. White, of Man- 
chester. But, while the general health of the woman is thus attended 
to, we must not overlook any special constitutional causes which may 
be in operation. The most important of these is undoubtedly syphilis, 
and the best chance of success in dealing with such cases is — whether 






XXII.] TREATMENT. 381 

the mother or father, or both, be affected — to bring them gently under 
the influence of mercury before coitus is again permitted. An examina- 
tion of the structures expelled in former abortions may seem to call for 
certain special means of treatment in addition to the general course of 
procedure above indicated. Diseases of the placenta or membranes act 
upon the foetus mainly by interfering with the oxygenation of the blood. 
It has been proposed, therefore, that an attempt should be made to 
introduce a superabundance of oxygen into the maternal blood, — an 
indication which it has been attempted to fulfil by inhalations of oxygen, 
or by the exhibition of such substances as contain a large proportion of 
oxygen in a state of feeble combination. It was with this object that 
Dr. Bower prescribed nitric acid, and Sir James Simpson the chlorate 
of potash. In the case of other diseases of the ovum or foetus, such as 
meningitis or peritonitis, mercury and other drugs have been prescribed 
on an analogous principle, in the hope of affecting the foetus through 
the maternal circulation, but so many difficulties are in the way of 
correct diagnosis in such cases, that little can be hoped for in the way 
of successful treatment. Indeed, with the single exception of the treat- 
ment of syphilis by mercury, we can place but little reliance on the 
medicinal treatment of habitual abortion, beyond what is administered 
with the view of giving tone to the system, or allaying constitutional 
disturbance. We must not, however, even where nature seems to defy 
us, in any case despair of success. Dr. Young, of Edinburgh, tells, in 
his lectures, of a case in which the patient actually miscarried thirteen 
times, and yet bore a living child the fourteenth time. In the most 
obstinate cases, a year's marital separation should be enjoined. 

The prevention of abortion extends, although in a somewhat differ- 
ent sense, to the treatment of cases in which the symptoms of impend- 
ing abortion have already manifested themselves. Having taken due 
cognizance of the symptoms which enable us to decide whether or not 
the loss of the ovum is inevitable, and being persuaded that there is 
room for hope, the efforts of the accoucheur will chiefly be directed to 
the expulsive contractions of the uterus. The success of his treatment 
will in fact depend upon the power which the remedies he may em- 
ploy will exercise upon this function of the uterus. Should any source 
of irritation exist, he must at once attempt to remove or to allay it. 
Bloodletting was at one time very generally employed in all cases, but 
is applicable only to those in which there is great arterial excitement, 
and a tendency to plethora. In these days, indeed, few practitioners 
would risk more than a few leeches to the perineum, and even that 
under very exceptional circumstances. The most perfect quiet of body 
and mind is more important perhaps than anything else. The patient 
should lie on her back on a hard mattress, and be kept cool. She 
should change her position as seldom as possible, for any exertion 
however slight will often be attended with a gush of blood. Her food 
should be light and easy of digestion; and not only stimulants, but 
animal food should in most instances be forbidden to her. Hemor- 
rhage is one of the alarming symptoms which we desire to arrest if it 
be possible, and on this account it is well to give the food cold, or at 
least cool. Caution must, however, be exercised, in the use of ice, 



382 PREMATURE EXPULSION OF THE OVUM. [CHAP. 

either internally or externally, for if, as is sometimes done, all the 
food is iced, and, in addition, cold affusion and injection resorted to, 
we may excite reflex action of the uterus, and thus defeat our ultimate 
object, although we may arrest the haemorrhage. With the view of 
arresting uterine action, nothing can be compared with opium, which 
is indeed our sheet anchor. This has succeeded even in cases where 
the discharge was alarming, and the os open to a considerable extent. 
To secure the full advantage of its sedative action, it must be given in 
full doses, so that forty minims of the Liquor Opii Sedativus in two 
doses, at an interval of twenty minutes, may be given in most cases 
without the slightest hesitation. This preparation has, we believe, the 
advantage which Rigby claimed for it over the other preparations of 
opium, that its sedative effect is more sure, and that it produces less 
irritation and derangement of the stomach and bowels. In other cases, 
again, in which it may be inadvisable to give opium by the mouth, an 
ordinary enema of starch with a drachm of laudanum will be preferred ; 
and, in point of fact, the possibility of having a local in addition to a 
constitutional effect, when it is administered in this way, will probably 
cause many to make choice of the method. Chloral, by the mouth or 
by injection, has also been employed with success. We must never 
despair so long as a chance remains of saving the ovum, bearing in 
mind that evidence of the death of the foetus is an immediate warrant 
for suspending all operations which have for their object the retention 
of the product of conception. It is a safe and good rule, however, 
that so long as we are not sure that the foetus is dead, we should act as 
if it were living. 

When violent pains, profuse haemorrhage, discharge of the liquor 
amnii, and progressive dilatation of the os, show that abortion is in- 
evitable, the treatment differs widely from the above, as the object of it 
now is to promote instead of to prevent expulsion. In the course of 
this process, however, there are so many steps to be gone through, that 
it often requires great nicety and discrimination to conduct a case to a 
successful issue, which implies the safety and speedy recovery of the 
mother. In the first three months the less we interfere the better. 
For, in these instances, as has been seen, the ovum often escapes entire, 
which is the most favorable occurrence possible ; while, if we interfere 
too much in the way of careless manipulation, we run the risk of rup- 
turing the membranes, discharging the liquor amnii, and thus causing 
a protracted retention of the whole or part of the ovum. The only 
symptom which is likely even thus early to call for energetic treat- 
ment is haemorrhage. It is unusual at this period for loss of blood 
to be a cause of much danger or alarm ; but if it should be so, we 
should not hesitate to plug the vagina. Of the various modes of plug- 
ging none is more simple or more effective than that which is recom- 
mended by Dr. Dewees. He advises that a piece of soft sponge, of 
sufficient size to fill the vagina without producing uneasiness, should 
be wrung out of pretty sharp vinegar, and introduced into the passage 
up to the os uteri : the blood in filling the cells of the sponge coagu- 
lates rapidly, and forms a firm clot, which completely seals up the 
vagina without producing any of those unpleasant effects which follow 



XXII.] MANAGEMENT OF THE PLACENTA. 383 

upon the insertion of a napkin rolled up for that purpose. There is 
this to be said in reference to the action of the plug, that while it 
may be looked upon as universally applicable in all cases of alarming 
haemorrhage, when all hope of saving the ovum has been abandoned, 
we should, if possible, avoid it in all other cases. It is an undoubted 
source of reflex contraction, and may thus precipitate labor in a hope- 
ful case. If properly applied, the plug may be left for a considerable 
time without interference, and may often be expelled with the'ovum. 
If removed, and the haemorrhage continues while the os is still con- 
tracted, there is no course open to us but to renew the plug, and this 
may always be done with the less hesitation, as it is well known that 
the risk of internal haemorrhage during the period of abortion is very 
trifling, and has rarely been observed earlier than the sixth month. 

As in the case of other haemorrhages, astringents are frequently given 
in abortion, sometimes with good effect. It is, however, in the earlier 
abortions in which this is most marked, when acetate of lead, gallic 
acid, and the mineral acids, may often be given with advantage. The 
more advanced the pregnancy, the less can we rely on ordinary astrin- 
gents ; so that we must then resort to oxytocics, with the view of 
exciting uterine contractions of such force as may expel the ovum, or 
such portion of it as may be retained. A simple enema, or one con- 
taining turpentine, will often serve as a powerful incentive to uterine 
action. If the abortion is one of the sixth month, we may sometimes 
be justified, when the haemorrhage is alarming, in rupturing the mem- 
branes, as in an ordinary case of accidental haemorrhage towards the 
end of pregnancy — a mode of treatment which was recommended by 
Puzos. More probably, even then, we would make choice of plug- 
ging, in preference to a mode of procedure which must even further 
remove any small chance of saving the ovum which might exist. 

It is the Expulsion of the Placenta, however, in regard to which the 
greatest difficulty is often incurred. If that period of pregnancy has 
been reached at which tins organ is distinct, the main difficulty would 
seem to arise from the firm anatomical connection which subsists be- 
tween the uterus on the one hand, and the placenta on the other. If, 
therefore, the whole ovum is not expelled entire, as is usual in the 
early weeks, the effect of the uterine contractions will probably be to 
rupture the membranes, and discharge the embryo or foetus through the 
cervix, which has been sufficiently dilated for this purpose. The action 
then ceases, the os closes, and the placenta is retained : so that here the 
analogy between abortion and labor at the full time ceases. 

This being the state of matters, we can do nothing but wait. The 
contracted state of the os prevents the introduction of the ringer, and 
ergot is often of little or no use; so that unless the haemorrhage is 
alarming, the safest course is to preserve an expectant attitude. When, 
after an interval of hours or days, as the case may be, haemorrhage re- 
curs, with pains more or less distinct, indicating further separation of 
the placenta and renewed uterine efforts, we must carefully observe the 
symptoms which are being developed, and manage the case accordingly. 
The haemorrhage may be so profuse as to require the plug, while we 
wait for the dilatation of the os. While this process is slowly being 



384 



PREMATURE EXPULSION OF THE OVUM. 



[CHAP. 



Fig. 131. 



effected, Ave may find that a portion of the placenta occupies the cervix, 
and can already be reached with the finger. Great caution should here 
be exercised ; and, if the haemorrhage is not alarming, it may be set 
down as a rule, that we should abstain from interference until there is 
some clear evidence of entire separation of the placenta, or until the 
os has reached a stage of more advanced dilatation ; and, even then, 
should all be going on favorably, it will be better to leave the process 
to nature, than to interfere, with the view merely of accelerating a 
process which nature is satisfactorily effecting. If we interfere prema- 
turely, we incur the danger of removing from the os a portion only of 
the placenta, upon which the closure of the os may again occur ; and, 
besides this, the flow of blood may thereby be actually increased, as 
the portion removed may have served as a natural plug. 

When the os is pretty well dilated, or when severe flooding calls for 
prompt action, the immediate removal of the placenta is of course our 
first object. With this in view, the finger is to be cautiously passed 
round the protruding portion, and, if necessary, another finger may be 
introduced into the os. If we can thus succeed in 
getting a hold of the placenta upon which we can 
rely, it may be extracted entire ; but a rude or un- 
skilful mode of manipulation may entirely frustrate 
our efforts by leaving behind a portion of what we 
wish to extract whole. It is impossible to lay down 
rules for the skilful performance of this manoeuvre, 
which can only be taught by experience; but we 
have no doubt that more reliance is to be placed 
upon the fingers than upon instruments, as a general 
rule. Levret recommended the injection of a pretty 
powerful stream of warm water, by means of a 
syringe, into the uterus, on the same principle as is 
adopted for the removal of wax or foreign bodies 
from the ear ; but the danger of intra-uterine in- 
jection, which modern practice has revealed, will 
probably deter most operators from adopting this 
plan. The placental forceps was devised by the 
same authority with the object of grasping and 
removing a retained placenta. Since then many 
varieties of this instrument, some of them most in- 
genious, have been constructed. Among others, Dr. 
Dewees recommended a wire crotchet, which he had used with good 
effect; and this, variously modified, has been not unfrequently em- 
ployed since his time. It must be confessed, however, that, whatever 
ingenuity may be exhibited in the construction of these, the fingers 
are almost always to be preferred ; and, if instruments are tried, they 
should only be used as auxiliary to the safer means of ordinary ma- 
nipulation. 

Should such attempts be attended only with failure, we must again 
plug, with the view of effectually restraining the loss of blood, which 
soon tells upon the pulse ; and the only other resource which remains 
to us is the use of ergot, or some other oxytocic agent. Upon ergot, 




Placental forceps. 



XXH.] PREMATURE LABOR. 385 

however, we must not depend, for the smaller the bulk of the uterine 
contents, the less is it to be relied upon ; but we are not, on that account, 
to be deterred from administering it, since it frequently exercises a 
remarkable influence upon the uterine fibre, even independently of 
pregnancy — as we have seen more than once in the case of uterine 
fibroids, where the physiological effect of the drug was an important 
element of diagnosis. 

Under ordinary circumstances, abortion is attended with but little 
risk to the mother, and the cases in which her life is placed in jeopardy 
are, therefore, relatively rare. Without taking into consideration the 
numerous instances in which abortion actually takes place, and is never 
recognized as such, this termination of pregnancy is of such frequent 
occurrence that the difficulties and dangers above described are only 
too familiar to the busy practitioner. I)r. Whitehead of Manchester 
made this a point of special investigation, and found that out of two 
thousand pregnant women, who had applied to the Manchester Lying- 
in Hospital, the total number of their abortions amounted collectively 
to one thousand two hundred and twenty-two. Thirty-seven out of 
every two hundred mothers had aborted before they had reached the 
age of thirty, and among those of a more advanced age the proportion 
of abortions was very much higher. It is, in point of fact, a rare thing 
for a woman to pass the greater part of the childbearing epoch in 
wedlock, without having aborted once, or oftener — which, along with 
the facts above cited, will suffice to show how enormous must be the 
loss of foetal life in the a^retrate. 

The treatment after abortion is a question of considerable importance; 
but, unfortunately, it is often a difficult matter to persuade a woman of 
the necessity which exists for the exercise of ordinary prudence and 
care. Under favorable circumstances, all that may be necessary is 
confinement to bed for a few days, and avoidance of fatigue and exer- 
tion for some time thereafter ; but, in other cases, more strict treatment 
may be necessary. Should retained fragments of placenta give rise 
again to haemorrhage, the patient must not be permitted to rise until 
all trace of this has ceased; and, if her general health has materially 
suffered, a course of chalybeate tonics, change of air, tepid sea-baths, 
and the like, must be resorted to, with a view of restoring the health. 
The great danger accruing from neglect of these precautions is not so 
much to be evinced in immediate effect as in the more remote results; 
and we are convinced, from long experience, that no more fruitful 
source of menstrual disorder or of chronic uterine disease exists, than 
what arises from a want of due precaution at this critical period of a 
woman's existence. 

But little of a special nature remains to be said of Premature Labor, 
which occurs only during the last three months of gestation — at a 
period, therefore, at which the child is held to be " viable." A vulgar 
idea very generally prevails, that children born at the eighth month 
are reared with more difficulty than those which are prematurely ex- 
pelled at the seventh ; but careful observation has clearly shown, what 
reason and analogy would have led us to conclude, that the further 
removed from the natural term of pregnancy is the period of delivery, 

25 



386 HEMORRHAGE BEFORE DELIVERY. [CHAP. 

the less chance is there of rearing the child. Many of the causes which 
have been enumerated as inducing abortion may also operate similarly 
at this more advanced period of pregnancy, but there are undoubtedly 
other special causes which may also be mentioned. The most impor- 
tant of these latter is over-distension of the womb, from whatever cause 
this may arise. Plural pregnancy, dropsy of the amnion, and hydror- 
rhea, are all causes of this nature ; and the immediate result of their 
operation is that the uterus attains, at a period much earlier than is 
usual or normal, that degree of distension which is characteristic of 
completed gestation. The symptoms and treatment of premature, labor 
differ in no essential particular from what obtains at the full term. If 
the dilatation of the os is somewhat tardy, a commensurate mechanical 
advantage is gained in the ease with which the fetus passes through 
the parturient canal. There is, however, without doubt, a greater ten- 
dency to retention of the placenta, although in a much less degree than 
in the course of the abortion period ;■ and, the nearer the delivery is to 
the natural term of gestation, the more strictly identical are the symp- 
toms with those of mature birth. 



CHAPTER XXIII. 

HEMORRHAGE BEFORE DELIVERY. 

"UNAVOIDABLE" AND "ACCIDENTAL" HEMORRHAGE — PLACENTA PREVIA; 
CENTRAL AND LATERAL: ORIGINAL IDEA AS TO THE NATURE OF: VIEWS OP 
RCEDERER AND RTGBY — CAUSES OF PLACENTAL PRESENTATION — SYMPTOMS : 
HEMORRHAGE BEFORE AND DURING LABOR: EXAMINATION FROM THE VA- 
GINA: OCCASIONAL TERMINATION BY EXPULSION OF THE PLACENTA, WITH 
CESSATION OF HEMORRHAGE : SYMPTOMS AND TERMINATION OF THE " LATERAL" 
VARIETY — TREATMENT: GENERAL MEASURES: USE OF THE PLUG OR TAM- 
PON : EVACUATION OF THE LIQUOR AMNII BY PUNCTURE OF THE MEMBRANES 
OR PLACENTA — TURNING IN PLACENTA PREVIA: PASSAGE OF THE HAND 
THROUGH THE PLACENTA AT ONE TIME PRACTICED : USUAL METHOD OP 
OPERATION — THE BIPOLAR METHOD — ARTIFICIAL EXTRACTION OF THE PLA- 
CENTA: SIMPSON'S STATISTICS — PARTIAL SEPARATION OF THE PLACENTA: 
BARNES'S VIEWS — GENERAL CONCLUSIONS AS TO TREATMENT — ACCIDENTAL 
HEMORRHAGE ; MORE SERIOUS THAN IS GENERALLY SUPPOSED — SITE OF THE 
PLACENTA — SYMPTOMS — TREATMENT — USE OF STYPTICS IN BOTH FORMS OF 
HEMORRHAGE. 

While haemorrhage prior to delivery is, as has just been shown, 
the rule in cases of premature expulsion of the ovum — a rule which 
indeed, at certain periods of abortion, admits scarcely of an exception — 
it is otherwise with labor at the full term. With the exception of the 
trifling hemorrhagic discharge constituting, at the termination of the 
first stage, what the midwives call a " show/' any loss of blood which 



XXIII.] PLACENTA PREVIA. 387 

precedes the birth of the child when mature, is in its nature abnormal. 
In practice, a certain number of cases are found to occur in which, in 
consequence of abnormal conditions, a serious loss of blood cccurs be- 
fore birth, so serious as in many instances to imperil the life both of 
the mother and her child. All cases of haemorrhage before labor do 
not, however, as will clearly be shown in the sequel, depend on the 
same cause; and, in consequence, the treatment applicable to each 
varies in relation to the cause which produces it. Dr. Rigby in his 
admirable essay on this subject, published now nearly a hundred years 
ago, divided cases of haemorrhage which occur in the last three months 
of gestation into those which are " unavoidable' 7 and those which are 
" accidental." Of the two, the former is the more important, and is 
familiarly known under the name of Placenta Prsevia; while the acci- 
dental form is due to the operation of causes which are similar in their 
nature, and in their mechanism, to the discharges which occur in 
abortion. 

Placenta P?'cevia, or Placental Presentation, as it has also with per- 
fect justice been termed, implies that the placenta, instead of occupy- 
ing its usual site in the neighborhood of the fundus uteri, is the lowest 
or most dependent part of the uterine contents, and occupies, wholly or 
partly, the passage through which the child has to pass. When it is 
attached to the entire circumference of the cervix, it is called "com- 
plete" placenta praevia, or Placenta Centralis; while, if it is adherent 
to a portion only of this area, it is usually designated as "partial" pla- 
centa praevia, or Placenta Lateralis. Such peculiar situation of the 
placenta necessarily involves its detachment from the subjacent uter- 
ine tissues with which it is in contact. This may take place, either 
gradually, in proportion as the cervix expands in the latter months of 
pregnancy, or more suddenly, when the mechanism of the first stage 
of labor tears asunder those attachments in the course of the uterine 
contractions which effect dilatation of the os. In either case, the 
haemorrhage from gaping vessels is in the strictest sense of the term 
" unavoidable," as it is impossible for the child to be born without 
haemorrhage of the most alarming description. There are, on this ac- 
count, few of the dangers of midwifery which the accoucheur dreads 
more ; and Naegele was probably right when he said that " there is no 
error in nature to be compared with this, for the very action which she 
uses to bring the child into the world, is that by which she destroys 
both it and the mother." 

The idea entertained by the ancients, and which (with the exception 
of those of Portal and Gifford) was taught in all works on midwifery 
down to about 1766, — when Roederer's Elementa Artis Obstetricice 
was published, — was that in these cases the placenta was originally 
attached at its usual site, and that it only fell down to the lower part 
of the uterus after it had been entirely separated. Roederer, in the 
work above referred to, gave as complete and succinct a description of 
placental presentation as is to be found in any modern work on ob- 
stetrics, and drew, moreover, a distinction between central and lateral 
implantation of the placenta. The work of Rigby, published a few 
years later, but which contains no reference whatever to the observa- 



388 HEMORRHAGE BEFORE DELIVERY. [CHAP. 

tions of Rcederer, is more familiar to English writers, and certainly 
was the first to bring a correct knowledge of the subject under the 
notice of English obstetricians, whatever may be the weight of the 
author's claims to originality. 

The Causes of placental presentation are but little understood. The 
fertilized ovum grafts itself, as is well known, generally, upon some 
portion of the uterine mucous membrane, not far distant from the ori- 
fice of the Fallopian tube along which it has descended. It has been 
presumed that, as the connection between the chorion and the decidua 
is — prior to the development of the placenta — continuous over the 
whole of their contiguous surfaces, the actual site of the placenta may 
correspond to any point in the circumference of the ovum. The tumid 
and convoluted condition of the mucous membrane which obtains 
during menstruation, and for some days afterwards, is obviously well 
suited to the arrestment of the fertilized ovum, a body already endowed 
with independent vitality, and prone to adhere to any surface from 
which may be derived the pabulum on which the maintenance of that 
vitality must necessarily depend. Exceptional circumstances may, 
however, occur to permit of the descent and ultimate escape of a fertil- 
ized ovum; and we may, therefore, infer that the ovum may, in any 
such case, be arrested near the cervix, and there go through the series of 
physiological changes upon which the formation of the embryo de- 
pends. The occurrence of extra-uterine pregnancy shows that contact 
with the membrane which is specially prepared for its reception is by 
no means essential to development of the ovum. There is nothing, 
therefore, extravagant in the assumption, that it may take root at a 
point of the uterine mucous membrane distant from the site which it 
ordinarily selects. It has even been held that the impregnation of the 
ovule may take place as low in the uterus as the cervix; and, if it be 
so, this will no doubt serve to explain the phenomenon in question. 
But, even if we suppose the ovule to be impregnated before its arrival 
in the uterus — which is, as is believed, the usual course — there are 
many special circumstances which may account for its occasional gravi- 
tation towards the cervix before contracting adhesions. If, for exam- 
ple, its descent is, relatively to the menstrual period, later than usual, it 
may find the mucous membrane no longer tumefied and convoluted to 
the same extent as before ; and there can be no doubt that a smooth 
and flat surface would be more likely to permit of such gravitation 
than the other condition of the membrane already referred to as charac- 
teristic of a menstrual period. The probable result of such a case 
would be loss of the ovum ; but it is at least possible that it might yet 
be arrested in its descent, and graft itself upon a surface to which it is 
accidentally contiguous, as when it falls upon the peritoneum in ab- 
dominal pregnancy. All such speculations are, however, merely theo- 
retical ; for it must be confessed that, in so far as the etiology of pla- 
centa previa is concerned, nothing definite is known. 

In the early months of pregnancy, there are no Symptoms which 
enable us to recognize the condition in question ; and, if hemorrhage 
should take place, it will probably be followed by abortion, in the 
course of which nothing would occur likely to direct our attention to 



XXIII.] SYMPTOMS OF PLACENTA PREVIA. 389 

the peculiar nature of the case. At any period more advanced than 
that at which abortions generally take place, a sudden attack of haemor- 
rhage, more profuse than usual, and for which no definite cause can be 
assigned, should always excite our suspicion, as it must neeessarily 
demand our attention. Such haemorrhages, dependent upon placental 
presentation, usually occur in the course of the last three months of 
pregnancy ; and the nearer the pregnancy is to its natural termination, 
the more profuse is the discharge likely to be. If this symptom should 
be of earlier occurrence than usual, the quantity will probably be slight, 
and, under favorable circumstances and judicious treatment, will speedily 
cease. After an uncertain interval, and often at what would have been 
the next menstrual period, the symptoms will, however, return with 
increased violence. Repeated haemorrhages of this kind, becoming 
progressively more alarming, ultimately attract attention, and call for 
assistance. The loss of blood in these cases probably depends upon 
the gradual development of the cavity of the cervix, which becomes 
further encroached upon with every day of advancing pregnancy. 

If at this stage we make an examination, we shall probably find that 
the os and cervix are somewhat peculiar to the touch. This peculiarity 
consists in a doughy feeling, due to the unusual thickness of the cervix, 
which is necessarily permeated with large vessels for the placental cir- 
culation. And this feeling is further exaggerated by the presence of 
the placenta itself, between the finger and the presenting part, depriv- 
ing the latter of its feeling of firmness and resistance. If the os is 
sufficiently dilated to permit the passage of the finger, the character- 
istic spongy tissue of the placenta may alone be felt ; or, if the case 
should be a lateral and not a central one, we may feel the edge of the 
placenta projecting at one side of the os uteri, and, possibly, the bag 
of membranes with the presenting part of the child at the other. If 
the flooding has been very severe, we may feel the detached surface of 
the placenta, which is lacerated and stringy to the touch ; and we may 
even discover, in some instances, where the separation has been exten- 
sive, a portion of the organ protruding into the os, or, through it, into 
the vagina. In presentations of the breech or shoulder, which usually 
remain high in the pelvis, the detection of placenta praevia is more 
difficult, partly on this account, and partly because the placenta can 
less easily be felt than when it is between the finger and the resistant 
structures of the cranium. 

There is another class of cases, in which no symptoms whatever 
occur until the uterine contractions at the commencement of labor in- 
terrupt, for the first time, the continuity of the utero-placental vessels. 
Here the gush of blood is sometimes so fearful, as to cause immediate 
syncope, and in some cases the death of the woman before assistance 
can reach her. Haemorrhage before labor, therefore, has this advan- 
tage, — that it enables us to recognize the nature of the case at a period 
sufficiently early to adopt precautionary measures, with a view to the 
patient's safety. From the commencement of labor, the symptoms in 
the two varieties are identical. Each successive pain tends still fur- 
ther to the separation of the placenta from its cervical attachments, 
and consequently to increase the haemorrhage, so that, up to a certain 



390 HAEMORRHAGE BEFORE DELIVERY. [CHAP. 

stage, the more advanced the labor, the more imminent is the danger; 
and, if left to themselves, such cases almost necessarily prove fatal. It 
is here that the important practical distinction is drawn which enables 
us, even without a digital examination, to distinguish between Una- 
voidable and Accidental haemorrhage, and which led Rigby to adopt 
this useful classification. In the former, remissions may occur between 
the pains, but with each contraction the flow of blood is increased ; 
while, in the latter, the descent of the head bars the egress of blood, 
the source of the discharge being higher in the uterus, as will be shown 
by and by, when we come to notice this special variety of flooding. 

It has been said that haemorrhage before labor is more likely to occur 
in cases of central than of lateral placenta praevia ; and if we were to 
draw an inference from the anatomical relation of the parts, we would 
be quite prepared to accept the correctness of this conclusion. Practi- 
cal experience has, however, shown that we cannot depend on this, and 
that many cases of central implantation present no symptoms whatever 
until these are developed by the occurrence of labor. 'It sometimes, 
though rarely, happens that the effect of the uterine contractions is to 
separate the placenta either from its cervical attachments or from its 
entire uterine connection, so that the haemorrhage is comparatively 
trifling. In some of these instances, the detached placenta has been 
propelled into the vagina, and the foetus then descending so as to 
press upon the orifices of the gaping vessels, has protected the woman, 
from that time onwards, from the further effects of alarming haemor- 
rhage. This has suggested a mode of treatment of these cases which 
will be mentioned at the proper place, and which is not without 
strenuous advocates at the present day. Another rare termination of 
central placenta, of which cases have been recorded by Portal and 
others, is the birth of the child through the placenta. A case of this 
nature occurred in the practice of Mr. White, of Heathfield in Sussex, 
and is given by Rigby. The placenta was " centrally attached to the 
os uteri, when, in consequence of two or three powerful pains, the head 
was forced through, tearing it quite across. The child was born dead, 
but the mother did well." Such natural terminations of placenta 
praevia are so rare, that not only do we place no reliance on them, but 
we do not even allow them to enter into our calculations in determining 
the mode of procedure which is to be adopted. It has even happened 
that in these cases children have been born alive; but it is obvious that 
the life of the child must, almost of necessity, be sacrificed. This is a 
further reason for not trusting to nature in the circumstances now 
under consideration. 

More confidence may, at times, be placed in the efforts of nature, 
when the case is a partial one, and the placenta situated laterally with 
respect to the os. As the placenta may be implanted upon any part of 
the internal surface of the uterus, a considerable variety of cases of 
partial placenta praevia may present themselves. In those cases in 
which the placenta spreads over a large portion of the cervix — and it 
has been observed that it is generally of greater superficial size than 
when it is developed at the fundus — the same treatment which is held 
to be applicable to central cases will be indicated. But, in the instances 



XXIII.] PARTIAL PLACENTA PREVIA. 391 

in which the bulk of the placenta is above the cervix, and a small por- 
tion only is implanted on that part, it is quite possible that, although 
labor may be ushered in by profuse flooding, the head may be permit- 
ted to descend, when it will act as a plug, and the natural powers will 
effect a safe delivery as regards both mother and child. And, a fortiori, 
when the placenta can only .be reached by the finger with some diffi- 
culty, this fortunate issue of the case is the more likely to occur; and, 
in fact, such cases should rather be looked upon as occupying a place 
intermediate between the " unavoidable" and "accidental" category. 
As is the case with regard to many other of the accidents of midwifery, 
there seems to be a proclivity to the recurrence of placenta previa in 
those who have once been the subject of it ; and another and stranger 
fact has also been noticed by Rigby, Saxtorph, Naegele, and others, 
viz., that at certain periods this accident seems of more frequent occur- 
rence than at others. The last-named authority, in remarking on this, 
states "that in some years, placental presentation was so frequent that 
it seemed as if it were almost epidemic." 

Treatment. — The occurrence of hemorrhage in the last months of 
pregnancy is of itself sufficient to warrant, and indeed demands, an 
immediate vaginal examination. Should the existence of the symptoms 
already detailed reveal the presence of the placenta at the os, the future 
management of the case becomes at once a matter involving no little 
anxiety. It has already been remarked that the earlier the period of 
pregnancy at which flooding first takes place, the less is the immediate 
risk. The treatment of such cases differs but little, as Rigby well 
remarks, from that of an ordinary case of abortion. The indications, 
in fact, are the same, viz., to stop the discharge, and allay any disposi- 
tion to uterine contraction. At the same time, no effort must be spared 
to prevent, if it be practicable, further separation of the placenta. 

Nothing is, perhaps, of such importance as rest. The patient should 
be placed in a bed which is as hard as is compatible with comfort. 
With the view of keeping her cool, the temperature of the room must 
be attended to, and the bedclothes should be light. The bowels mav 
be managed by gentle saline laxatives or enemata, and the patient 
should not be permitted to raise her shoulders ; nor, for a certain time 
after an attack, should she ever be allowed even to move in bed more 
than is absolutely necessary. The food at first should be of the lightest 
possible description, such as milk, arrowroot, and the like, and should 
be given cool. Such restricted regimen cannot be persevered in for any 
length of time, so that we must soon introduce soups, fish, chicken, and 
more nourishing material generally into the dietary. The use of 
stimulants, except in so far as they may be necessary in the stage of 
depression, consequent on severe flooding, must be forbidden. Under 
such treatment, and with the mind as well as the body at perfect rest, 
the best chance is afforded the woman of reaching the full term of ges- 
tation. The probable result of haemorrhage, in placenta previa prior 
to the seventh month is, as has been said, abortion. But, when gesta- 
tion is further advanced, and the foetus has reached the period of 
viability, we endeavor to avert premature delivery as long as is pos- 
sible, in order to give the child the best possible chance. But we do 



392 HEMORRHAGE BEFORE DELIVERY. [CHAP. 

this in the interest of the mother also, and not exclusively in that of 
the child. Of the operative remedial measures which may be adopted, 
none is so frequently resorted to as turning, and the nature of the 
operation is such that it may always be effected with greater ease to the 
operator, and less risk to the woman, the nearer the case is to the full 
term. 

When haemorrhage and vaginal examination have revealed the nature 
of the case, at any time during the last three months of gestation, we 
should inform the patient and her friends of the certainty of a recur- 
rence of the flooding sooner or later. The number of the attacks, and 
the period which may elapse between them, are points on which we 
dare not venture an opinion. In one case, the flow may be almost 
continuous, or have remissions only ; and, in another, there may be but 
one or two attacks, and these not seldom corresponding to menstrual 
periods. But the great peril, in every case, lies in this — that we can 
never foresee the moment when a torrent of blood may be poured out 
in such abundance, that the life of the woman is placed in instant jeop- 
ardy, and may be sacrificed before assistance can reach her. Particular 
directions should therefore be given, in order that no time be lost in 
summoning assistance. It is, moreover, of the highest possible impor- 
tance that a skilful nurse should be in constant attendance, to whom 
the accoucheur may give instructions as to the method of plugging — 
the materials for which should be kept prepared and constantly at 
hand. 

The use of the vaginal plug or tampon, as applicable to the treatment 
of abortion, has already been described. The proceeding in this case 
is precisely similar, and the material recommended on the authority of 
Dewees will here suit the purpose equally well. The object of plugging, 
if practiced before labor has commenced, is simply to prevent the flow 
of blood, without there being any ulterior object, as regards further 
operative procedure, in view. This is effected partly by preventing 
the external flow, and partly by compressing the placenta between the 
plug and the presenting part of the child, and thus artificially damming 
up the source from which the blood has escaped. Although, as already 
remarked, the sponge is to be preferred on various grounds, it, and the 
coagulated blood which accumulates in its interstices, are so prone to 
decomposition, that it cannot well be retained beyond a few hours. In 
such cases, then, as it may seem advisable to maintain compression of 
the placenta for a longer period, it may be better to plug with slips of 
lint, tow, or some other similar substance; or, better still, by an india- 
rubber bag, which, after its introduction, may be distended either with 
water or with air. Braun's Colpeurynter is a contrivance of this nature. 
The plug must not, however, be used rashly in those cases in which 
the haemorrhage is as yet trifling, and in which, consequently, we are 
justified in temporizing, in the hope of preserving the child; for ex- 
perience, derived from the treatment of abortion cases, has clearly shown 
that the irritation of the plug is pretty sure, sooner or later, to excite 
uterine contraction. Where labor pains, however feeble, have already 
manifested themselves, or where the urgency of the symptoms precludes 
the hope of conducting the case to maturity, this particular action of 



XXIII.] TREATMENT OF PLACENTA PRiEVIA. 393 

the plug is rather an advantage, as, by stimulating the uterine fibres, 
the os is more rapidly and effectually dilated. Astringents, local and 
general, have been tried in every possible way in these cases, but it 
must be confessed that their action is not even in the slightest degree 
to be depended upon ; a result which will not excite wonder if the 
purely mechanical cause of the haemorrhage be kept in mind. 

When the flooding does not occur until labor has declared itself at 
the termination of pregnancy, or when, at any period, the haemorrhage 
is so profuse, and the general symptoms so urgent as to demand ener- 
getic action in the presence of a great emergency, our duty is to encourage 
contraction, and to complete delivery as soon as possible. With this 
object prominently in view, various modes of treatment have been rec- 
ommended, to each of which it is necessary specially to advert. In a 
large proportion of the cases in which the os is as yet undilated to any 
extent, the only justifiable mode of procedure is to arrest the haemor- 
rhage by plugging, and, at the same time, to favor uterine contraction 
by every means at our command. Plugging is, however, as will be 
observed, in all cases of placenta prsevia, a mere temporary expedient, 
which is employed with a view to ulterior proceedings. 

Evacuation of the liquor amnii by puncture of the membranes is a 
practice of great antiquity. The object of this in the present instance 
is to develop uterine energy, which usually becomes increased when its 
walls are thus relaxed ; while, at the same time, being of smaller bulk, 
it acts with greater energy. The cases to which this mode of procedure 
seems more particularly applicable, are those instances in which the 
placenta is situated more or less laterally, or, in other words, those in 
which the membranes can be reached before the os has become dilated, 
and without much risk of rupture of tissue. Its use, however, has not 
been confined to such cases, but has been recommended and practiced 
by Deventer, Deleurye, Smellie, and, more recently, by others, who, 
in cases of central implantation, puncture the placenta by a trocar or 
otherwise, with the result of arresting the haemorrhage. Rupture of the 
membranes is also applicable to all cases in which it is found expedient 
to induce premature labor, that is to say, if it can be effected with safety; 
but, if not, of coui'se other means must be adopted to rouse the uterus 
to activity. Dr. Barnes says, " The puncture of the membranes is the 
first thing to be done in all cases of flooding sufficient to cause anxiety 
before labor. It is the most generally efficacious remedy, and it eon 
always be applied. 9 ' The italics are his, indicating the emphasis with 
which he makes the statement, but in so far as our experience enables 
us to judge, we cannot indorse his assertion. And, moreover, we cannot 
but think that such a procedure as he describes of guiding a stilet or 
quill along the finger to the membranes must necessarily cause, for a 
tiuie at least, an increase in the bleeding in central cases, as it certainly 
must a complete and violent separation of the placenta in a part of its 
circumference. The contraction of the uterus may be further promoted 
by the action of ergot and the other oxytocics. Evacuation of the 
liquor amnii and the use of ergot are, it must be remembered, open to 
this objection, that, by such treatment, the difficulty of the operation 
of turning is greatly increased, should that operation eventually be 



394 HEMORRHAGE BEFORE DELIVERY. [CHAP. 

found necessary ; but if the operation for separation of the placenta is 
to be preferred, as is recommended by Dr. Barnes, this objection has 
no force. 

The operation of turning, which will be more particularly described 
in another chapter, is that to which most modern authorities, with some 
distinguished exceptions, give the preference in the treatment of cases 
of placental presentation. So long as this operation is looked forward 
to as one suitable to an individual case, not only must rupture of the 
membranes not be practiced, but every means should be adopted which 
is likely to preserve their integrity. We shall not here anticipate the 
details of the ordinary operation of turning, but notice only those modi- 
fications of the operation which are rendered necessary by the peculiar 
anatomical conditions of the case. Two methods have been suggested. 
That to which Dr. Rigby has lent the weight of his authority, consists 
in forcing the hand through the tissues of the placenta into. the amni- 
onic cavity, and then completing the operation in the usual way. Dr. 
Dewees urges the following cogent and unanswerable objections against 
this procedure : 

" 1. In attempting this, much time is lost that is highly important 
to the patient, as the flooding unabatingly, if not increasingly, goes on. 

"2. In this attempt, we are obliged to force against the membranes, 
so as to carry or urge the whole placentary mass towards the fundus of 
the uterus ; by which means the, separation of it from the neck is in- 
creased, and, consequently, the flooding augmented. 

" 3. When the hand has even penetrated the cavity of the uterus, 
the hole which is made by it is no greater than itself, and, consequently, 
much too small for the foetus to pass through without a forced enlarge- 
ment; and this must be done by the child during its passage. 

" 4. As the hole made by the body of the child is not sufficiently 
large for the arms and head to pass through at the same time, they 
will consequently be arrested ; and if force be applied to overcome this 
resistance, it will almost always separate the whole of the placenta from 
its connection with the uterus. 

" 5. That, when this is done, it never fails to increase the discharge, 
besides adding the bulk of the placenta to that of the arms and head of 
the child. 

" 6. When the placenta is pierced, we augment the risk of the child; 
for, in making the opening, we may destroy some of the large umbilical 
veins, and thus permit the child to die from haemorrhage. 

" 7. By this method we increase the chance of an atony of the uterus, 
as the discharge of the liquor amnii is not under due control. 

" 8. That it is sometimes impossible to penetrate the placenta, espe- 
cially when its centre answers to the centre of the os uteri ; in this in- 
stance much time is lost that may be very important to the woman." 

These and similar arguments, and the experience of modern practice, 
have resulted in a general, if not invariable, preference for the second 
method of performing the initiatory stage of the operation of turning. 
The origin of the procedure referred to is generally attributed to 
Portal. The hand, in this case, is to be passed, not through, but by 
the side of the placenta, choosing, if it be possible to ascertain the fact, 



XXIII.] TREATMENT OF PLACENTA PRiEVIA. 395 

that side to which the placental adhesions are least extensive. It is 
very rare that the attachment is equal in extent all round; and, of 
course, if there is any point of the circumference to which the placenta 
is not adherent, that place should be selected for the passage of the 
hand. The usual precautions are to be adopted for preventing rupture 
of the membranes, and the hand is to be carried high into the uterus 
between it and the membranes, until the situation of the feet is ascer- 
tained, when the fingers are thrust through them, the feet seized, and 
the operation completed in the usual way. During the course of this 
procedure, — which is often easier of execution than under ordinary 
circumstances, owing to the relaxed state of the uterus, the result of 
haemorrhage, — the arm of the operator acts as a plug, which effectually 
restrains external haemorrhage. When the feet are brought down into 
the vagina, the breech and trunk of the child forcibly compress the 
placental mass ; and in this way one plug is replaced by another more 
efficient still. The action of the womb should be aided by an external 
bandage, or by firm pressure, at this period, over the fundus, and a full 
dose of ergot may be administered, with the view still further of 
insuring efficient contraction. If the child is still alive, or if there is 
no evidence of its death (in which case we should act as if it were alive), 
delivery must be effected as rapidly as is consistent with the safety of 
the mother. With its birth, the critical period of danger will have 
passed, and the uterus will now contract firmly upon, and shortly expel 
the mass of the placenta which is left behind. 

When the accoucheur is summoned at the commencement of labor, 
on account of the alarming flooding, he will probably find that the os 
is not sufficiently dilated to permit of the operation of turning with a 
reasonable prospect of safety. His first duty at this stage is to arrest 
the haemorrhage, until such time shall arrive as the condition of the 
parts may warrant him in proceeding to the operation. This can only 
be effected by the action of the plug, which is to be introduced in the 
manner above described. Or, what is more effectual still, strips of lint 
may be introduced, one after the other, through the speculum, as by 
this means the vagina can be more thoroughly packed. As the pressure 
of the plug is apt to interfere with the action of the bladder, it will be 
well to see that the viscus is empty before its introduction. A still 
more effectual method of plugging may at this stage be practiced by 
means of the fiddle-shaped water-bags, which we owe to the ingenuity 
of Dr. Barnes. A certain amount of dilatation is necessary for the 
successful application of these ; but if the os is of sufficient size to admit 
the point of the finger, it will then be practicable to pass a bag of small 
size. This may then be distended with water in the manner described 
by the inventor, and a firm elastic plug is thus formed, which serves 
the double purpose of preventing any escape of blood, and, at the same 
time, of mechanically dilating the os by a safe and graduated method 
of pressure. The exchange of the small bag for one of larger size may, 
after an hour or so, be effected without much risk, if the operator is 
dexterous ; and, in this way, such dilatation of the os may be effected 
as will admit the passage of the fingers, and subsequently of the hand. 



396 HEMORRHAGE BEFORE DELIVERY. [CHAP. 

But, whether we make use of the vaginal or cervical plug, the object is 
to dilate the os, with the view of subsequent operative procedure. 

It is to be remembered that extensive dilatation of the os is by no 
means essential to the successful performance of the operation of turn- 
ing. The method of combined external and internal manipulation, 
which has already been referred to in. the chapter on Transverse Pres- 
entations, and which will be more particularly described, affords a 
mode of procedure which is by no means difficult, and which is cer- 
tainly safer to the mother. To effect this, the passage of one or two 
fingers through the os is all that is necessary; and in so far as placenta 
prsevia is concerned, we are convinced that this method is peculiarly 
applicable, and will ultimately, in a great measure, displace the more 
familiar operation. 

"The conditions favorable for turning are," says Dr. Tyler Smith, 
"a dilated or dilatable state of the os uteri; the retention of the liquor 
amnii, or a moderately relaxed state of the uterus; a pelvis of average 
capacity ; the absence of dangerous exhaustion, or a temporary cessation 
of the haemorrhage." Nothing is of greater importance than that the 
operation should be attempted as early as possible, for there can be no 
doubt that the great mortality which attends these cases is due in no 
small degree, to an injudicious expectant treatment, while the precious 
moments pass during which alone we can save the patient's life and 
that of her child. It may sometimes be necessary, when the case does 
not come under observation until this more advanced and critical stage, 
to delay the operation, and to plug, until the woman is rallied by free 
stimulation from the state of incipient collapse into which she has fallen. 
In this, as in all other cases of prostration from haemorrhage, brandy 
given along with opium will effect the object in view as well perhaps 
as any other combination of stimulants which it is possible to prescribe. 
When, in such cases, the pulse and general appearance show that the 
woman has rallied, the operation may be commenced, and conducted 
with the special precautions which the circumstances demand. 

In some cases of partial placenta prsevia, the operation of turning 
may not be required ; but if in such the haemorrhage is still alarming, 
after the head has descended so as to occupy a fully distended os, the 
labor may be completed by the application of the forceps. 

Artificial Extraction, and Artificial Separation of the Placenta — for 
it is proper to draw a distinction between the two — are operations which 
were suggested by what has occasionally been observed as a natural 
termination of placenta prsevia, viz., the birth of the placenta or its 
expulsion into the vagina in advance of the child, with cessation of the 
haemorrhage. Imitating this, Drs. Wood, Radford, and Simpson, tried 
what had previously been done in a few cases, to separate and extract 
the placenta, in the hope of speedily arresting the haemorrhage, and 
thus insuring the safety of the mother. Simpson, with his usual and 
indefatigable industry, collated a table, in which cases are given show- 
ing the results to the mother in instances of turning. Contrasted with 
this, is another series of cases, in which the placenta was expelled nat- 
urally or removed artificially before the birth of the child. The fol- 



XXIII.] TREATMENT OF PLACENTA PREVIA. 397 

lowing represents in a tabular form, the results of his elaborate sta- 
tistics : 

Cases. Maternal Deaths. 

Turning, 654 180, or 27.48 per cent. 

Extraction or Expulsion, . . 140 . . 10, or 7.14 per cent. 

Such an issue as is represented by these figures is by no means, how- 
ever, a fair representation of the comparative risk attendant upon the 
two operations. On the contrary, by grouping together the cases in 
which natural expulsion had occurred with those in which the removal 
had been accomplished by operative interference, the value of the com- 
parison is lost, as it must be evident that expulsion is less likely to be 
attended with a fatal result than those cases in which the parts are torn 
asunder by an operation which, how r ever gently performed, implies a 
rupture of tissue by violence, involving the integrity of large vascular 
trunks. Although the figures are to this extent unreliable, it must be 
admitted that the cases upon which they are founded show quite clearly 
that separation of the placenta, whether natural or artificial, is accom- 
panied in a large proportion of cases with an abatement, dependent upon 
the arrest of hemorrhage, of the more alarming symptoms. " Paradox- 
ical as it may appear," says Simpson, " there are sufficient grounds and 
facts for believing that, when the placenta is separated slightly and 
partially, the chance of fatal haemorrhage to the mother is greater than 
when the disunion of the organs is entire and complete." 

It would serve no good purpose to follow the discussion to which 
Simpson's views as to the source of the haemorrhage in placenta praevia 
gave rise. These are essentially the same as were held by his prede- 
cessor, Dr. Hamilton, that the blood flowed not from the uterine, but 
from the placental orifices of the ruptured vessels, a point which, 
although of high physiological interest, must not divert our attention 
from the more important practical questions upon which it has but an 
indirect bearing. We must not omit to mention that the operation of 
extraction is, as regards the child, extremely unfavorable in its ultimate 
results — more so, certainly, than turning, if performed at the proper 
time. In this, also, Simpson's statistics are likely to mislead, if not 
carefully analyzed. Again, grouping together indiscriminately cases 
of expulsion and extraction, he finds that, in 141 cases, the child was 
saved in 33, and, as the result as regards the child was not stated in a 
considerable number of the remaining cases, it may be assumed that the 
actual number of children born alive was somewhat larger than is 
above stated. But here again the same source of fallacy comes into 
j^lay, and, in point of fact, it may be assumed that the statistical results 
of spontaneous expulsion and artificial extraction should be carefully 
separated, otherwise the figures are very apt to encourage errors in 
practice. When the foetus is born by the efforts of nature, it has often 
been found to be expelled by the same pain which brings the placenta 
into the world, or at least follows it within a very few minutes, a result 
extremely improbable in artificial extraction. Dr. Simpson's own tables 
point conclusively to this fact, and in those cases in which the interval 
between the birth of the placenta and that of the child was more than 
ten minutes, he gives but one instance, occurring in the practice of Mr. 



398 HEMORRHAGE BEFORE DELIVERY. [CHAP. 

Perfect, in which the child was born alive. Unless then it could be 
proved that a speedy delivery of the child could be depended upon after 
extraction of the placenta, that operation cannot be looked upon with 
favor, in so far at least as the interests of the child are concerned. 

But, should we even resolve upon the operation of extraction, the 
difficulties of the case do not terminate with the completion of that 
operation. Thus we find that, of the entire number of 86 cases given 
by Simpson in his tables, delivery was effected by turning in 25 in- 
stances, and by other modes of operative procedure in 7, while in 9 the 
mode of delivery is not specified. This leaves 45 cases only in which 
the delivery was completed by the natural pains, and we may confi- 
dently conclude that, if w r e could separate the cases of spontaneous 
expulsion, the issue of the operative cares would appear still more un- 
favorable. The inference which was drawn from Simpson's elaborate 
papers on this subject, and the interpretation which indeed seemed to 
attach to them, was that the author wished to supersede the old opera- 
tion of turning by that of artificial separation. We might think it 
necessary to say something more in refutation of such a conclusion, were 
it not that the practice has never commanded general support, save under 
exceptional circumstances. And, moreover, a careful reperusal of Simp- 
son's facts, arguments, and conclusions, seems very clearly to show that, 
whatever opinions may have been entertained by that distinguished 
accoucheur when he submitted his views to the Medico-Chirurgical 
Society of Edinburgh in 1844, those were materially altered before his 
death. This appears even more clearly from the " Lecture Notes," by 
which the reprint of his selected obstetrical works recently edited by 
Dr. J. Watt Black is prefaced. 

We shall now refer to the mode of partial separation, which has of 
late years received a considerable amount of support. It is intimately 
associated with the name of Dr. Barnes, whose writings on the subject 
of placenta previa are among the most valuable of the many contribu- 
tions to obstetrical literature which we owe to the distinguished obstetric 
physician of St. Thomas's Hospital. The effect of the uterine contrac- 
tions, and consequent dilatation of the os, is, as he has shown, to sepa- 
rate the placenta in concentric rings from below upwards, vessel after 
vessel being thus opened, and the haemorrhage proportionally increased. 
So soon as the separation has reached a certain height, the passage of 
the head may become possible, while yet an amount of placenta suffi- 
cient to discharge the function of the organ may remain attached. Dr. 
Barnes maintains that the complete separation of the placenta as 
recommended by Simpson is impracticable. "In by far the greater 
number of cases," he says, " the placenta extends higher than the 
meridian of the uterus, often reaching the fundus. The fingers are not 
long enough to reach even half way towards the further margin of the 
placenta. The diameter of the placenta is nine or ten inches ; the fin- 
gers will barely reach three inches. In the greater number of cases, 
therefore, in which the directions prescribed have been followed, the 
placenta has not been wholly detached, and the result, when successful, 
cannot be attributed to an operation which was not performed." As- 
suming this fact to be correct, and supposing, therefore, that to insure 



XXIII.] TREATMENT OF PLACENTA PREVIA. 399 

vom'plete separation of the placenta, the whole hand must be passed into 
the uterus, he adds that this operation " is even more severe than turn- 
ing, which does not require the hand to be passed through the cervix." 
Here he obviously refers to the bipolar method. There is, he infers, a 
zone or line around the lower part of the uterine cavity above which 
spontaneous detachment and haemorrhage do not occur, and below which 
alone separation and unavoidable haemorrhage take place. 

On this hypothesis, then, the real period of danger is that during 
which the placenta is being separated from the cervical zone, and Dr. 
Barnes maintains with great confidence that this is the mode of action 
in many of the cases which have been narrated of spontaneous cessa- 
tion of the flooding, the real facts being misinterpreted by the observer. 
In a case which recently occurred in the experience of the writer, the 
facts observed seemed strongly to corroborate the idea thus suggested, 
in regard to which he had previously been more than skeptical. A 
young woman, pregnant for the second time, had had several attacks 
of haemorrhage prior to the expiry of her pregnancy. With the first 
labor pains another gush took place, and shortly after this she was first 
seen and examined by him. He found the os sufficiently dilated to 
admit a single finger, and the placenta completely surrounding the 
orifice. During several successive pains it was observed that the quan- 
tity of blood was for such a case very trifling, and it was on that ac- 
count resolved to leave the case for a time to nature, with the view of 
observing what course nature would adopt. Materials were prepared 
for plugging the moment this should seem to be necessary, and the 
case was anxiously watched. Soon afterwards pains came on of great 
violence, and in rapid succession, but there was only one short period 
of about a minute and a half, during which the haemorrhage was 
alarming, which suddenly ceased upon the rupture of the membranes. 
Upon an examination the head was now felt descending, and the 
woman was shortly afterwards safely delivered of a living child. She 
made an excellent recovery. 

Whatever may be the method of treatment upon which it is resolved 
to act, the first difficulty generally is to effect the dilatation of the cer- 
vix with the least possible chance of haemorrhage. Dr. Barnes, be- 
lieving that the tardy separation of the placenta from what he terms 
the " orificial zone " of the uterus is the main cause of haemorrhage, 
recommends that, if rupture of the membranes, which is his first pro- 
cedure, should fail, we ought at once to separate the whole of that part 
of the placenta which is adherent to the zone in question. The de- 
tails which he gives are as follows : "Pass one or two fingers as far as 
they will go through the os uteri, the hand being passed into the va- 
gina if necessary ; feeling the placenta, insinuate the finger between it 
and the uterine wall ; sweep the finger round in a circle, so as to sepa- 
rate the placenta as far as the finger can reach ; if you feel the edge of 
the placenta where the membranes begin, tear open the membranes 
freely, especially if these have not been previously ruptured; ascertain 
if you can what is the presentation of the child before withdrawing 
your hand. Commonly some amount of retraction of the cervix takes 
place after this operation, and often the haemorrhage ceases. ... If 



400 HEMORRHAGE BEFORE DELIVERY. [CHAP. 

uterine action return so as to drive down the head, it is pretty certain 
there will be no more haemorrhage; you may leave nature to expand 
the cervix, and to complete the delivery. The labor, freed from the 
placental complication, has become natural." Failing this, he then 
advocates the use of his hydrostatic dilators, which at once expand the 
os, and arrest the bleeding. These bags, which we have had occasion 
repeatedly to use, and which we have ventured to suggest as applicable 
to the plugging and dilating of the os prior to turning, admirably serve 
the purpose of dilatation. After an hour or half an hour, the bag may 
be withdrawn, and if then the uterus remains inactive, with a contin- 
uance of the haemorrhage, or if the presentation turns out to be trans- 
verse, or otherwise abnormal, which is very common in placenta pre- 
via, the operation of turning is then to be resorted to by the bipolar 
method. On a total of 69 cases treated by Dr. Barnes on this princi- 
ple, the percentage of maternal deaths was only 16.66. 

The various methods above described may be conveniently epitom- 
ized for practical purposes in the following propositions, in which it is 
attempted to give its proper value to each : 

1. That the Evacuation of the Liquor Amnii is specially applicable 
to cases of lateral or partial placenta praevia, and other cases in which 
the membranes can be easily reached; and to cases in which the feet us 
is immature. 

2. That Ergot and other oxytocics may be administered, but it is to 
be remembered that both these and evacuation of the liquor amnii act 
so as to render the operation of turning more difficult. 

3. That Plugging is called for at various stages, and may be applied 
either in the vagina or in the os uteri. It is a mere temporary expe- 
dient, and, in the case of turning, is an almost essential mode of pre- 
liminary treatment. 

4. That extraction of the placenta, although not so impracticable as 
Dr. Barnes supposes, is not to be resorted to unless the circumstances 
be very exceptional, as when the operation of turning is impossible, 
and that of separation has failed. 

5. That Separation of the placenta, which has sometimes been con- 
founded with Extraction, is a much more justifiable procedure than 
the latter. It may be performed in all cases in which the condition of 
the parts or the state of the mother prohibit turning; but the evidence 
in its favor is not as yet sufficiently clear to warrant us in abandoning 
the older operation of turning. That it arrests haemorrhage in a con- 
siderable proportion of cases is admitted, but until a more extended 
experience shall corroborate the conclusions of Dr. Barnes, it would 
be unwise to admit them as proved. Statistics in such a case are of 
little value, and this Dr. Barnes himself frankly admits. 

6. That the operation of Turning is that in which the great majority 
of experienced practitioners still place the greatest confidence. If the 
percentage of maternal deaths under this treatment is, as Simpson says, 
as high as 27.48, including all cases indiscriminately, we are certainly 
bound to conclude that in those instances in which the patient is under 
treatment from the first, the results will be very much more favorable. 
If the plug bars the haemorrhage, as it generally does when properly 



XXIII.] ACCIDENTAL HEMORRHAGE. 401 

applied and carefully watched, that stage of the process must be ad- 
mitted as effectual. But it is not to be forgotten that the operation of 
turning is one which involves special risks, of which laceration of the 
os and cervix, terminating in uterine phlebitis, is not the least, and that, 
therefore, we must weigh well the responsibilities we undergo before 
we reject all other modes of procedure in favor of this operation as it 
is usually performed. The risk, however, has been greatly modified 
by the introduction of the bipolar method of version. 

The so-called Accidental Haemorrhage differs in many essential par- 
ticulars from the unavoidable variety commonly called placenta praevia. 
The designation is, of course, more an arbitrary than a philosophical 
one; but as it is one generally intelligible to English readers, we shall 
not attempt to change it. In this case also, there is haemorrhage before 
delivery, but there is a most important clinical distinction to be drawn 
between the two. In the last three months of pregnancy the anatomical 
connection which subsists between the uterus and the placenta becomes 
more feeble, so that the one is more easily separated from the other. 
The wonder then is, not that the separation does in rare instances occur, 
but that it does not occur more frequently. In accidental haemorrhage, 
the placenta is attached to the uterus at its normal site. 

What the causes are which, in such circumstances, lead to a separa- 
tion of the placenta are but little known or understood, but it has been 
observed that the separation rarely occurs in the young and robust; 
while, in those who have borne many children, or in whom any cause 
may have led to constitutional feebleness, it is relatively of more fre- 
quent occurrence. If, in such cases, the flooding is to be looked upon 
as a symptom of constitutional depravity, that of itself renders the 
case a grave one; but another source of hidden danger is that the 
haemorrhage is often concealed. Placental separation indeed occurs; 
blood is insinuated between the membranes and the uterus; obvious 
shock and even collapse is produced ; and yet no single drop of blood 
escapes externally, while laceration of the uterine wall has occurred 
from the over-distension of the cavity by a haemorrhage such as this. 
In other cases, again, the placenta has remained adherent at its margin, 
while an enormous quantity of blood has been effused between the uter- 
ine wall and the body of the placenta. It would appear that, in many 
cases, the separation of the placenta takes place in the centre and not 
at the margin, and that the blood makes its way towards the margin, 
and thence frequently beneath the membranes, until it makes its ap- 
pearance externally. These are the cases which, although by no means 
so treacherous or so dangerous as the former, are generally described 
as accidental haemorrhage. In some of them, the general symptoms 
are as severe as those which accompany a case of placenta praevia, and 
in others are much more grave than the actual external flow would 
seem to account for. Sickness, pallor, dimness of vision, and fatal 
prostration may thus rapidly supervene in a case of this nature, before 
even the symptom of flooding has attracted any particular attention. 

Accidental haemorrhage may occur either before or during labor. 
The great diagnostic feature which, according to all authorities, from 
Rigby downwards, enables us to distinguish, during labor, between it 

26 



402 HEMORRHAGE BEFORE DELIVERY. [CHAP. 

and unavoidable haemorrhage, is that, in the latter, the effect of a pain 
is to increase the flooding, by still further separating the placenta; in 
the accidental form of haemorrhage, the presenting part descends during 
a pain, and thus, by plugging the cervix, stops the external flow. 

[It is not every case of this sort that is attended with a discharge of 
blood externally, and these "concealed accidental haemorrhages" are 
probably not so rare as authors represent them to be. Dr. William 
Goodell, of Philadelphia, has analyzed one hundred and six examples 
of this accident. The most prominent symptom is collapse. This is 
alarming from the very first, and carries "dismay into the heart of 
the bystander." The skin becomes cold ; is bedewed with a clammy 
perspiration. The pulse is feeble and flickering, and the patient suffers 
from difficulty of breathing, sighs and retches frequently, and finally 
faints. At the same time the woman has an agonizing pain, with a 
sense of distension in the uterus as if it were bursting. The labor pains' 
are very feeble or entirely absent. This while there is no sign of haemor- 
rhage externally, but some time after the effused blood has become co- 
agulated a watery discharge may take place from the vagina. This is 
generally supposed to be the liquor amnii, but upon examination the 
membranes are found to be intact, proving that the fluid is the liquor 
sanguinis, which has worked itself outwards between the membranes 
and the uterus. In some instances the blood after a time begins to 
flow from the vagina. Some authors, among whom are Levret, Hopff, 
Leroux, and Baudelocque, have attached great importance to the de- 
velopment of an " accessory tumor" of the uterus, the result of bulging 
of the walls from the accumulated blood. This is not a constant symp- 
tom. It occurs when the margins of the placenta remain adherent. 
This assemblage of symptoms is certainly very striking, and when they 
appear in women who were previously perfectly healthy, they are cal- 
culated to excite the utmost alarm upon the part of both the patient 
and her friends. 

The accident is liable to be mistaken for rupture of the uterus, from 
which it can be distinguished by the fact that in concealed haemorrhage 
the size of the abdomen continues to increase, while in rupture it dimin- 
ishes, especially if the child escape into the abdominal cavity. In rup- 
ture the head recedes from the os, or the bag of waters becomes flaccid 
if it have not broken ; though rupture is rare until after this occurs. 
In concealed haemorrhage the bag continues tense. In rupture, the 
pains, until the moment of the accident, have generally been unusually 
violent, when they cease suddenly. In concealed haemorrhage they are 
very feeble or entirely absent from the first. 

Dr. Goodell, to whose admirable description of this accident we are 
indebted for the above facts, mistook it for a severe attack of " cramp 
colic." The diagnosis may be very difficult, but the fact that the 
woman is pregnant is of considerable importance, while the syncope of 
the mother, and failure of the fcetal circulation would point to the 
true cause of the symptoms. A serous discharge from the vagina, the 
membranes remaining intact, is a symptom of great value, and sets all 
doubts at rest. — P.] 

Many writers seem to pass over these cases, as if they were of little 



XXIII.] ACCIDENTAL HAEMORRHAGE. 403 

importance, and were as nothing beside the more interesting physio- 
logical speculations which arise from a consideration of placenta prsevia. 
In point of fact, however, they are extremely fatal to the child, and 
highly dangerous to the mother, so that their management involves, in 
some instances, no less anxiety than placenta prsevia itself. In so far 
as Treatment is concerned, the first step in accidental haemorrhage is,i>^ 
undoubtedly, to rupture the membranes, so as to give egress to the 
liquor amnii. This, by removing the strain on the uterine walls from 
within, has a well-known tendency to promote vigorous expulsive 
action on the part of that organ. It is, besides, the most efficient safe- 
guard which it is possible to procure, for a pain not only plugs the os, 
by forcing down the foetus, but, what is more important, it compresses 
the placenta between the uterus and the child, and, by the same action, 
mechanically closes the mouths of the vessels from which the blood has 
flowed. Friction, ergot, and if there be much depression, stimulants, 
may also be used, with the object of encouraging uterine action in those 
cases in which it is feeble or absent. But these means may fail to excite 
efficient uterine action, and the expulsion of the uterine contents, upon 
which alone we can depend for the safety of the mother. Should this f 
be the case, our next step, after indulging, in the absence of actual 
haemorrhage, in a reasonable amount of expectancy, should be to dilate 
the cervix gradually, by means of Barnes's bags, and to complete de- 
livery by the operation of turning, in which the bipolar method should 
always, if it be practicable, be preferred. The previous evacuation of 
the liquor amnii will, no doubt, render the manoeuvre of turning more 
difficult than it would otherwise have been ; but, on the other hand, 
as it is failure of uterine action which calls for the latter operation, the 
atony of the uterine walls will generally compensate for the absence of 
those conditions wdiich are usually held to be favorable to the perform- 
ance of the operation of turning. The greatest possible care should, 
in every case, be taken to avoid precipitation in the course of the 
manipulation, and thus to preserve the integrity of the tissues of the 
cervix. 

The peril of the woman does not necessarily terminate, either in 
unavoidable or accidental haemorrhage, with the birth of the child, or 
even with the expulsion or extraction of the placenta. The uterine 
fibres may remain in such a paralyzed condition that flooding may still 
go on from the patent orifices of the uterine vessels. In such an emer- 
gency it may, therefore, be necessary to apply some powerful styptic to 
the bleeding surface, with the view of arresting the jjost-partum haemor- 
rhage, an object which, in the case of placenta prsevia, may be most 
effectually attained by swabbing the cervical zone with perchloride of 
iron, alum iron, or some other astringent; but, in the case of the 
accidental variety, it may be necessary, in order to reach the bleeding 
surface, cautiously to inject the cavity of the uterus with the same 
powerful agents. Another source of anxiety in all these cases, even 
when the immediate dangers of the haemorrhage and operation have 
been surmounted, is the risk of puerperal pyaemia and the allied affec- 
tions, to the development of which such patients are peculiarly prone. 



404 HEMORRHAGE AFTER DELIVERY. [CHAP. 



CHAPTEE XXIV. 

HAEMORRHAGE AFTER DELIVERY. 

hemorrhage in the third stage of labor — abnormal and retained pla- 
centa, and irregular uterine contraction, as causes of flooding — 
post-partum hemorrhage — causes: general and local — symptoms: 
of external and internal hemorrhage : examination of the abdomi- 
nal walls : examination by the vagina : general symptoms ! symptoms 
avhich indicate the approach of death — treatment: prevention: 
treatment during the hemorrhage : pressure and friction over the 
uterine region — effects of bandaging — effect of passing the hand 
into the uterine cavity — application of cold, should not be continu- 
ous — astringents to internal surface — galvanism — ergot — treat- 
ment by plugging abandoned — views in regard to compression of the 
abdominal aorta — application of the perchloride of iron and other 
styptics: objections to, and arguments in favor of this procedure — 
dr. barnes's process — treatment directed to the general condition 
of the patient — effects of rest and position — reaction to be avoided 
after severe flooding — transfusion: the "mediate" and "imme- 
diate " processes : dr. aveling's apparatus ; injection of defii3rinated 
blood, and of saline solutions. 

Although haemorrhages which precede the expulsion of the placenta 
are not, properly speaking, post-partum, we shall, for convenience sake, 
consider them here. The proper management of the placenta, with 
the object mainly of preventing haemorrhage, has already been ex- 
plained in the chapter on the Management of Labor; but there are 
some other important matters which are still left for consideration, and 
as some of these have strong analogies with true post-partum haemor- 
rhage, it has been thought better to include them in this section of our 
subject. Retention of the placenta, and consequent haemorrhage, may 
be the result of mismanagement, but, independently of this, there are 
other causes, over which we have little or no control. If the circum- 
stances attending the labor are in all respects normal, the placenta is 
probably separated entirely, either during the birth of the child, or in 
the course of the dolor es cruenti which follow it. In a certain number 
of instances, however, the placenta is not separated in this manner; 
owing, in one class of cases, to some anatomical peculiarity in the form 
of the placenta, in a second to atony, in a third to irregular contrac- 
tion of the womb, and in a fourth to what has been described as morbid 
adhesion. 

Cases of abnormal placenta, in which the organ is divided, or has 
detached cotyledons, are of such rare occurrence that no practical im- 
portance can be supposed to attach to them. A full account of these is 



XXIV.] RETAINED PLACENTA. 405 

given, with beautiful illustrations, in a recent work by Hyrtl. 1 Should 
atony of the uterus be the cause, we must attempt without delay to ex- 
cite uterine contraction by friction, cold applications, or ergot. In 
such a case, we have a double cause of haemorrhage in operation, — an 
absence of the contractile force upon which the closure of the bleeding 
vessels depends, and a mechanical hindrance to that contraction in the 
presence of the placenta. Of irregular contractions of the uterus,* that 
which is most frequently spoken of is " hour-glass " contraction, in 
which a spasmodic stricture of certain fibres of the uterus divides the 
organ into two cavities, within the upper of which the placenta is im- 
prisoned. True placental adhesion depends, again, on actual disease 
of the decidua or placenta, or, at least, on the presence of morbid prod- 
ucts which are the result of antecedent disease. 

In all these cases, the treatment is the same, and consists in the 
speedy removal of the placental mass, or masses. If there is a loss of 
expulsive force, the hand is to be passed, w r ith the usual precautions, 
into the uterine cavity, so as to grasp the whole placenta. A pause 
should, however, be made here until contraction takes place, which is 
to be further aided by the pressure of the hand on the walls of the ab- 
domen, so that, if possible, the placenta and the hand may be expelled 
together. If this is not done, the placenta may indeed be extracted, 
but, in such a case, flooding of the true post-partum variety can hardly 
fail to take place from the flaccid organ. If the so-called hour-glass 
contraction should be found to exist, the efforts of the operator must, 
in the first place, be directed to the stricture, which has to be over- 
come before the extraction of the placenta can be safely effected. There 
is no doubt, however, that hour-glass contraction is of much less frequent 
occurrence than is generally supposed. It is a familiar expression, 
and is apt to be employed loosely, as representing all forms of irregu- 
lar uterine contraction in which the extraction of the placenta is a 
matter of difficulty. When the uterus contracts irregularly, this ma- 
terially affects the process of separation of the placenta, besides mechan- 
ically hindering its extraction. The gradual insinuation of the hand 
into the womb, and the introduction of one or two fingers into the 
contracted portion, so as gradually, by gentle but sustained efforts', to 
overcome the morbid spasm, or other condition, which is indirectly the 
cause of the haemorrhage, is the treatment which is applicable to such 
a case. It requires no great force to wear out a spasm of this nature, 
and although at first it may be almost tetanic in its rigidity, it will 
gradually yield, and, by permitting the passage of the hand, admit of 
the easy removal of the placenta. When the cause of haemorrhage is 
the adhesion of a partially separated placenta, it is sometimes necessary 
to introduce the hand, and forcibly strip the organ from its uterine 
attachments. This peeling process, which must be conducted very 
slowly and steadily, will often occupy a considerable time ; but, fortu- 
nately, the cases in which the operation is required are of rare occur- 
rence. It would appear, that in some of these instances at least, the 
uterine tissue, with which the placenta is in such intimate connection, 

1 Die Blutc;efasse der menschlichen Nachs:eburt. Wien. 1870. 



406 HEMORRHAGE AFTER DELIVERY. [CHAP. 

is morbidly soft and friable, so that the operator runs the double risk 
of leaving behind adherent portions of a placenta, the bulk of which 
has been removed, and of injuring the uterine walls, which are no 
longer, in their structure, such as to admit of even ordinary force. Do 
what we may, portions of placenta are sometimes left behind, which 
may require to be removed as the causes of subsequent haemorrhage, or 
which may afterwards be spontaneously discharged, — a result which 
may, although very unjustly, be set down to the discredit of the ac- 
coucheur. Such retained masses have been removed, when unusually 
adherent, by the wire- rope £craseur. 

In so far as the ordinary and normal condition of the placenta is 
concerned, the best safeguard against the haemorrhage in question is the 
proper management of the placenta during, and subsequent to, the birth 
of the child. This has already been described in another section of this 
work. 

True Post-partum haemorrhage is an alarming and sometimes, in its 
effects, an appalling occurrence. When, in the course of labor, every- 
thing has passed as favorably as could be desired, the child is born 
alive, and the mother is apparently well, we naturally anticipate, as 
experience has taught us, a happy issue to the case. But the termina- 
tion of labor, the real hour of trial to the mother, maybe the beginning 
for her of a new and unforeseen peril. One of the essential physiological 
phenomena of labor is, as has been shown, the efficient contraction of 
the uterus during and after the birth of the child. This is nature's 
almost invariable safeguard. At times, unhappily, the uterine fibres 
which close the bloodvessels are relaxed, and blood pours forth with an 
impetuosity proportionate to the calibre and relaxation of the vessels, 
deluging the woman with blood, and reducing her in extreme cases to a 
condition of collapse which may be the immediate forerunner of death. 
So fearful is the torrent, in the worst cases, that, before we even have 
time to arrange our plan of treatment, our patient lies dead before us. 
The more experience one has of the practice of midwifery, the more do 
we dread the occurrence of this form of haemorrhage, which we can 
seldom foresee, and which is therefore all the more appalling, since we 
have seen no occasion to nerve ourselves and to prepare for an approach- 
ing emergency. 

Causes. — A certain number of cases are, no doubt, due to slovenly 
practice, a neglect of those details which should be matter of routine in 
every case. But, while such causes may generally be avoided by ordi- 
nary skill and attention, there are other instances where the causes upon 
which the flooding depends are comparatively little, and sometimes not 
at all, within our control. One of the most important and, at the same 
time, most common cause of post-partum haemorrhage is uterine inertia. 
It may be that in these cases the uterine effort is simply exhausted, and 
complete atony is the immediate sequel of labor. Anything which may 
have tended to reduce the vital powders may lead to this. In women 
who have long suffered from wasting diseases, whose constitution may 
have been exhausted by many rapidly succeeding pregnancies, or in 
whom the vital energies have been in a measure sapped by a long- 
continued or complicated labor, we see illustrations of those conditions, 



XXIV.J CAUSES. 407 

which are predisposing causes of haemorrhage after labor. No small 
proportion of the fatal cases seem to have occurred in women who were 
the subjects of the more advanced stage of Bright's disease, or of any 
similar disease which exercises a deteriorating influence on the compo- 
sition of the blood, increasing the watery at the expense of the corpus- 
cular elements. It has been observed that, when the labor is unusually 
rapid, either from violent expulsive effort or deficient resistance, there 
is a tendency to post-partum flooding. It would appear, therefore, 
that a condition of safety is gradual emptying of the uterine cavity. 
In this way the fibres have time to contract to the enormous extent 
which is essential to the effectual closure of the vessels ; whereas, sadden 
contraction, although possibly efficient enough as regards delivery, 
cannot maintain itself, and is often followed by subsequent intermittent 
periods of relaxation, during which flooding is almost sure to occur. 
This, no doubt, is the reason why, after delivery by the forceps, and 
in some other obstetrical operations, flooding is more frequently ob- 
served, — an excellent and sufficient warrant for the strict observance of 
the obstetric aphorism, that we should empty the womb in operative cases 
as slowly as possible, and allow it to contract upon the child as it is 
being expelled. Sometimes, however, anxiety for the life of the child 
and other circumstances may lead us, for what may seem good reasons, 
to disregard this maxim ; but, in doing so, we should always admit into 
our calculations the fact that, in avoiding one danger, our pilotage may 
cause us to make shipwreck on another somewhat more remote. 

Fibroid growths connected with the uterus, and especially fibroid 
polypi are, if present, almost certain causes of haemorrhage after labor. 
It is well known that haemorrhage is one of the earliest and most con- 
stant symptoms of this affection in the nn impregnated state, and it is 
not therefore to be wondered at that the proclivity to flooding should 
be more marked at the critical period which immediately succeeds 
delivery. This symptom may be caused in two ways, either by haemor- 
rhage from the mucous surface of the tumor, or by the mechanical 
interference which it exercises in preventing the proper closure of the 
venous orifices in the wall of the uterus. 

Another affection may here be mentioned as an undoubted cause, and 
which, although it has not the slightest pathological affinity with the 
tumor just described, may be, and has by very experienced observers 
been, mistaken for it. We allude to inversion of the uterus. The 
symptoms of this, which will be more fully noticed in another place, 
are indeed such as, under ordinary circumstances, could scarcely be 
mistaken. In the one, we have a tumor generally ovoid in shape, con- 
nected with a pedicle which we can trace up to the os or beyond it to 
its intra-uterine attachment ; in the other, we have also an ovoid tumor, 
but which ends abruptly by a more extensive attachment, within easy 
reach of the finger. In the former case, we find the distal extremity 
of the tumor encircled by a ring, formed by the os uteri more or less 
contracted ; in the latter, there is no such constriction. But this, be it 
remembered, applies only to the diagnosis of complete uterine inversion, 
which must pass, slowly or more rapidly, through various stages before 
it becomes complete, and at any one of these it may be arrested. In 



408 HEMORRHAGE AFTER DELIVERY. [CHAP. 

other words, there may be partial as well as complete inversion, and it 
is the former condition only which is likely to be mistaken for a polypus. 
In a case which, many years ago, came under our notice, there was a 
rounded tumor narrowing towards its upper part and tightly embraced 
by the os, and it was this condition which led to an erroneous diagnosis. 
In a precisely similar case, one of the best known and most distinguished 
accoucheurs in Britain made a similar error, but fortunately discovered 
his mistake, just as he was about to remove the tumor by the ecraseur, 
by the pain which the patient complained of, and which he knew by 
experience was a most unusual symptom in manipulating polypi. Let 
us beware, therefore, of mistaking a partially inverted uterus for a 
polypus which is protruding from the uterine cavity. 

The Symptoms of post-part urn haemorrhage are flooding, or the general 
symptoms to which it gives rise, or both of these combined. In by 
far the greater number of instances, the external discharge is at first, 
and throughout the whole course of the case, the most alarming, as it 
is the most palpable sign. It may immediately succeed the birth of 
the child, or may precede or follow the expulsion of the placenta. The 
quantity of the discharge is very variable, and upon this will depend, 
in a great measure, the opinion which we may form as to the gravity of 
the case. Generally, symptoms, more or less distinct, of uterine inertia 
will be manifested. The firm tumor which we are accustomed to feel 
behind the pubes loses its distinct outline, and becomes less perceptible 
to the touch ; or may disappear altogether, so that we can perceive 
nothing but softness and flaccid ity. We may then feel parts, such as 
the projection of the last lumbar vertebra and the promontory of the 
sacrum, which we know to be separated from the fingers by the tissues 
of the womb. If the inertia or atony of the uterus is complete, this 
condition is persistent, and on introducing the hand into the cavity, 
which may generally be effected with ease, we find that the uterine 
walls are soft throughout, and, as Cazeaux graphically describes it, 
" folded together like a piece of old linen/' Such a condition, should 
it precede the separation of the placenta, may exist without haemor- 
rhage; but, if the third stage of labor has been completed, flooding is 
inevitable. In many of these cases, however, it will be to the observer 
a matter of wonder that the haemorrhage should not be more profuse. 
Sometimes there are efforts on the part of nature to effect uterine con- 
traction, when the hand, in the hypogastric region, may detect alter- 
nate relaxation and contraction of the organ, the latter periods being 
accompanied with the expulsion of such blood as may have accumu- 
lated within the cavity during the former. This disposition to rhyth- 
mical action on the part of the uterus is not to be looked upon with 
unnecessary apprehension, unless the actual flow of blood, or the general 
symptoms, are grave. 

The absence of alarming external haemorrhage is a negative symp- 
tom, which may divert the attention of the inexperienced from the true 
nature of the case. In some of these cases, bleeding may be going on 
internally to an extent which may rapidly place the woman in a posi- 
tion of extreme peril. The continuous absence of the uterine tumor, 
and the formation, subsequently, of an extensive and soft abdominal 



XXIV.] SYMPTOMS. 409 

swelling, progressively increasing in size, will, along with the general 
symptoms which rapidly develop themselves, soon indicate what is 
going on. The conditions under which such symptoms may manifest 
themselves, are — first, a state of the uterus which admits of easy dila- 
tation ; and, second, anything which mechanically impedes the external 
flow, Any displacement of the flaccid womb which may close the ex- 
ternal orifice mechanically, is sufficient, in the first instance at least, to 
check the flow in the direction of the vagina, Subsequently, the occlu- 
sion of the orifice with a clot, which will form a more effective plug if 
the os and cervix should be in any degree contracted, and at an earlier 
period, the pressure of the wholly or partially detached placenta, may 
in this way form a barrier which, under ordinary circumstances, would 
speedily be swept away, but which, in the utterly flaccid and dilatable 
condition of the uterus, may be sufficient for the development of the 
phenomena in question. Sometimes, this process of distension is ac- 
companied with great agony, which is not the result of attempted con- 
traction of the organ, but of the morbid phenomenon of over-distension, 
an indication which is not (infrequently noticed in distension of the 
other hollow viscera. If the hand of the operator is now introduced 
into the cavity of the womb, he will recognize still more clearly the 
condition of matters, and he will find his fingers entangled in an enor- 
mous mass of clots, with which, and with fluid blood, the cavity is 
distended to an extent which may equal the size of the organ at the 
natural period of mature gestation. 

The general symptoms which indicate post-partum haemorrhage may 
exhibit themselves equally in external and internal haemorrhage. They 
are, unfortunately, familiar to all experienced practitioners; but, as 
symptomatic of the accidents we are now considering, they are, for 
obvious reasons, of greater importance in those instances in which the 
haemorrhage is internal. In the worst cases, the symptoms are truly 
appalling, and in the course of a very few minutes the loss of blood 
may be so enormous as to plunge the woman, almost without warning, 
into a state of fatal syncope. In cases which, though less desperate, 
are scarcely less alarming, the woman may, with or without previous 
abdominal pain, and with or without external haemorrhage, experience 
a feeling of faintness associated with marked pallor. The vision be- 
comes dim, and she calls out that she can no longer see; vomiting fre- 
quently occurs ; and the extremities and general surface of the body 
become cold and bedewed with a clammy perspiration. The pulse 
becomes rapid, small, or imperceptible; and the paleness becomes so 
marked, so greatly exceeding all others, that Dr. Tyler Smith has 
called it " Puerperal Pallor." In some cases, however, the effect on 
the circulation is such as to produce, in the first instance, what is 
familiar to surgeons as the " hemorrhagic pulse," a symptom which is 
apt to mislead the inexperienced. This is a bounding and apparently 
full pulse; but, if its character be more carefully tested, it is found to 
be remarkably compressible, and soon, with a continuance of the flood- 
ing, merges into the more familiar condition of feebleness and imper- 
ceptibility. 

Such symptoms are manifestly indicative of a state of extreme peril, 



410 HEMORRHAGE AFTER DELIVERY. [CHAP. 

and, if prompt and skilful treatment be not speedily afforded, are too 
often the precursors of death, which may be preceded by dilatation of 
the pupil, hysterical paroxysms, or even by convulsions. It has fre- 
quently been observed that the amount of blood lost is not a safe cri- 
terion of the danger ; for not only are we apt to be deceived in regard 
to the amount of internal haemorrhage, but there is the greatest pos- 
sible variety in the symptoms which, in different women, attend a loss 
of a precisely similar amount; and it may be added that it is not in- 
variably the strong and robust who bear haemorrhage best, or recover 
most rapidly from its effects. In those cases in which haemorrhage 
after labor is due to a laceration more or less extensive of the os, or of 
any other portion of the parturient canal, the symptoms are rarely 
such as to excite alarm. The dangers to which such occurrences give 
rise are of a different nature, and do not manifest themselves till a later 
stage. 

Treatment. — There are, perhaps, few practical questions involving 
more anxious consideration than this. The young practitioner may 
find an illustration in the first case of midwifery which he is summoned 
to attend. He has no time for reference to books, no moment even 
during which he may appeal to his memory for facts which have escaped 
it ; and he must, therefore, be fully prepared by a thorough acquaint- 
ance with the subject, or he is unable to cope with so great an emergency. 
The principles on which all treatment depends, demand, then, his care- 
ful attention. 

It is perhaps scarcely possible to attach too great importance to the 
prevention of post-pa rtu in haemorrhage. Much will depend upon a 
proper management of the various stages of labor, retarding the action 
when this has a tendency to be precipitate, promoting it when the pains 
are feeble, and acting otherwise as has been recommended in the chap- 
ter on the management of labor. The importance of never leaving a 
woman until you are satisfied with the uterine contraction after delivery 
will, in view of the circumstances above stated, now become more mani- 
fest. We can never be sure of the case unless we are satisfied on this 
point. There are certain points here, however, which, if not under- 
stood, might result in the nirnia diligentia of the tyro. First, it must 
ever be borne in mind that each case of labor is accompanied in its 
last stage with a certain amount of haemorrhage, and this is not unfre- 
quently considerable, without being accompanied, either then or sub- 
sequently, with any other symptoms which should excite alarm. A 
second circumstance which may cause needless alarm is the gush of 
liquor amnii, mixed or colored with blood, which immediately follows 
the birth ; and a third consists in what we very frequently observe, a 
certain amount of alternate contraction and relaxation which may seem 
to resemble, in some degree, the conditions above described. An erro- 
neous inference, drawn from these observations, we have known to lead 
to treatment which was energetic enough certainly, but quite unneces- 
sary, and, moreover, not unattended with risk. Caution must, there- 
fore, be exercised, lest, by giving undue prominence to one symptom 
without reference to the others, needless panic and improper interfer- 
ence is the result. 



XXIV.] TREATMENT. 411 

There are cases in which the history of previous labors, no less than 
the circumstances attendant on that which is going on, indicate, at least, 
the probability of a similar result, and in such it is always proper 
towards the end of the second stage, or at least before the extraction of 
the placenta, to administer ergot with the object of insuring efficient 
contraction ; and the same agent may be used in all cases in which, 
after the expulsion of the placenta, there is a tendency to atony. More- 
over, we would do wrong, knowing what we do of the effect produced 
upon the uterus by excitation of the nipples, were we to omit to have 
the child placed early to the breast. These means, along with the 
application of the abdominal bandage, and the other details which have 
previously been fully described, constitute what is called preventive 
treatment. 

The course of procedure, to be adopted in actual presence of the 
emergency, is the real question which may task our knowledge, our 
nerve, and our ingenuity to the utmost. The object which, before all 
others, we have in view, is to promote uterine contraction, and if we 
fail in this, we fail utterly. Of the various methods which we have at 
command, that which is invariably first employed is manual pressure 
exercised upon the fundus of the uterus, and also upon its lateral walls, 
by attempting to grasp the whole organ. In doing this, we do not so 
much depend upon the effect of such mere mechanical compression, as 
upon the more indirect action whereby the uterus is excited to contract, 
a result which is further encouraged by circular friction exercised over 
the fundus of the organ. The effect of the abdominal bandage at this 
moment certainly is to aid contractile effort, by affording a substitute 
for the support which has been lost by the inevitable relaxation of the 
abdominal walls. The bandage is, however, no advantage, but the 
contrary, when it prevents us from ascertaining and, when necessary, 
continually watching the condition of the uterus and its relation to the 
abdominal walls. It is best to have it loosely attached, so as to admit 
of easy removal and reapplication, and by placing one or more folded 
towels over the hypogastric region, the compression of the uterus is kept 
up continuously, and is not temporary or intermittent as that of the 
hand necessarily must be. Should this not be immediately followed 
by satisfactory uterine contraction, the hand should be passed into the 
vagina, so as to ascertain the condition of the uterus more exactly. 
Sometimes the irritation of the cervix which is thus caused, results, 
with the aid of the external hand, in the action so much desired ; but 
should the organ remain in a state of complete atony, the hand must 
be passed into the cavity, in order still further to stimulate contraction 
by contact with its internal surface. When the hand is so passed, it 
should be moved about w T ithin the womb, so as to collect, as far as 
possible, within the palm, the clots which occupy the cavity. This 
movement will generally suffice to awaken uterine action ; but in every 
case we must be careful not to remove the hand except during sensible 
contraction, w T hen the uterus may be permitted, as it were, to expel the 
hand, and with it the retained clots. 

The reflex effect of cold in producing uterine action is often well 
marked. This may be applied either to the abdominal or thoracic 



412 HEMORRHAGE AFTER DELIVERY. [CHAP. 

walls, to the vulva, or by injection to the rectum or vagina. It has 
often been observed, even in cases in which the action of this powerful 
agent was at first marked, that its continuous action is not to be depended 
on. However effectual, therefore, it may seem in the first instance, 
when applied suddenly by the douche or otherwise, the action should 
not be sustained ; otherwise an effect the reverse of beneficial is apt to 
be produced. The injection of the uterine cavity with iced water, or 
the application to the inner uterine surface of a piece of solid ice is, 
under circumstances of emergency, quite justifiable, and has often 
proved efficacious. The alternated action of heat and cold has been 
found more useful than sustained cold, the latter agent acting in two 
ways as an astringent and an excitor of uterine action. M. Evrat 
recommended the use of a peeled lemon, which he introduced into the 
cavity of the uterus and then squeezed, so as to project the acid juice 
upon the bleeding surface. A sponge wrung out of vinegar and other 
astringents have, in the same way and for the same purpose, been intro- 
duced, and the effect of such applications has not un frequently been to 
rouse the uterus from its dormant condition. Galvanism has also been 
employed with good effect, and may always, if immediately available, 
be tried. In cases in which clots again form within the cavity of the 
womb, these should be removed, as by presenting a mechanical impedi- 
ment to feeble contraction they encourage a continuance of the flooding; 
and, as before stated, it is well to allow the hand and the clots to be 
simultaneously expelled by uterine action, should it be possible to 
arouse the organ to such an effort. 

In the worst cases, little dependence can be placed in the use of ergot, 
for before sufficient time has elapsed to admit of the physiological action 
of the drug, the patient may be dead. If employed, it is to be given 
in full doses, and at as short intervals as is possible. The stomach will, 
however, often reject it, as indeed, when the patient is in a state of 
extreme collapse, it will reject anything solid or fluid which may be 
swallowed. This is not to be looked upon as in itself an unfavorable 
occurrence, as it has often been observed that violent retching is attended 
with uterine action, so much so indeed that some practitioners have 
actually prescribed ipecacuanha with the view of obtaining its emetic 
effect. Plugging, as a method of treatment, is of ancient origin, and 
has been advocated in modern times by Leroux and others who adopted 
his opinions; but, as it has proved inefficacious, it has been abandoned. 
The mode of action must obviously have been, whether the plug was 
applied in the vagina or within the womb, to convert external into 
internal haemorrhage, and in no sense, therefore, to benefit the patient. 
The last attempts of this nature which have been made would seem to 
have consisted in the introduction within the uterus of Gariel's air 
pessary, which was then distended in the hope of compressing the 

bleeding vessels, an effect which a more correct knowledge of the con- 

... . 

dition of the uterus will not permit us to count upon. 

The flaccid condition of the abdominal walls which immediately 

succeeds delivery, enables us, without difficulty, to press upon, and 

more or less effectually arrest the flow of blood through, the aorta. In 

desperate cases, therefore, the compression of this great vessel has been 



XXIV.] USE OF STYPTICS. 413 

practiced, in order to arrest the torrent which continues to pour from 
the uterine vessels ; but the practice has by some been violently opposed 
on theoretical grounds. Baudelocque maintained continuous pressure 
upon the aorta for several hours, and imagined that in this way there 
was at least a gain of time, during which ergot and other agents might 
act, and the strength of the woman be restored. The most weighty 
objection to the practice is obvious, in the fact that the source of the 
haemorrhage is not so much in the curling arteries as in the venous 
sinuses, so that aortic compression cannot be supposed to exercise a 
very decided effect. But there is, moreover, another objection which 
has been urged, viz., that it is scarcely possible to compress the aorta, 
without at the same time subjecting the vena cava to more or less 
pressure, so that directions have been given whereby the pressure is to 
be directed to the left side of the vertebras, in order to avoid the vena 
cava. Cazeaux believes that the result of such compression of the vena 
cava should be looked upon as rather a favorable condition than other- 
wise; and we are certainly inclined to agree with him in thinking that, 
in the worst cases, the volume of blood can only be accounted for by 
supposing that it proceeds, by regurgitation, from the great venous 
trunks. Two methods of compression of the aorta have been recom- 
mended ; in the one, the vessel is compressed through the abdominal 
walls, and in the other the hand is passed into the uterus, and the 
vessel closed — as is assumed, more effectually — by pressure through 
the posterior uterine wall. While it must be confessed that the results 
of this procedure have not been such as to encourage us to look upon 
it wjth anything like confidence, there still seems to be in it a ray of 
hope, to which, w T hen all else may have failed us, we cannot close our 
eyes. By all means, therefore, let aortic compression be tried. There 
is certainly no evidence upon which we can rely, that the practice has 
ever been productive of harm, while many believe that it, at least, 
arrests temporarily the rapid downward tendency which is so charac- 
teristic of a considerable proportion of such cases. 

The application, not of astringents merely, but of powerful Styptics, 
to the inner surface of the uterus, is a mode of treatment which has, 
during the last few years, attracted considerable attention in this coun- 
try. The procedure is not a new one, and even as regards the styptic 
salts of iron, which are, undoubtedly, the best, they were originally 
used by D'Outrepont, and also by Kiwisch, who, upwards of twenty- 
five years ago, strongly supported this method of treatment. The 
action of such powerful agents is looked upon by most practitioners 
with considerable apprehension, and that it is so, is not, perhaps, to be 
wondered at. Nothing is more unjustifiable than such a procedure, 
unless, in the first instance, other means have been tried, and have 
failed to arrest the flow of blood ; but in the presence of a great danger 
and instant peril, the objections to the application of styptics have less 
force. We do not wish in any way to undervalue these objections; 
but even admitting their validity, and viewing the operation in the 
light of a desperate remedy, the facts which are given by Kiwisch, and 
recently, in this country, by Dr. Barnes, are such as to afford us much 



414 HEMORRHAGE AFTER DELIVERY. [CHAP. 

encouragement, and warrant us, in cases of emergency, in availing 
ourselves of this method of treatment. 

It is proper, however, to notice here the dangers which may arise 
from the injection of perchloride of iron, which have been very fairly 
put by Dr. Barnes, who is the chief supporter in this country of the 
bold employment of the more powerful styptics. The perchloride 
produces immediate coagulation of any blood with which it may be 
brought in contact, but the danger to be dreaded is, that such coagula- 
tion might extend further ; and, should coagula be carried to the centre 
of circulation, death would be the probable, if not the inevitable, result. 
Immediate death has followed the injection of even a few minims into 
a nsevus, and in one such case which is quoted by Dr. Barnes, " ex- 
amination showed that the point of the syringe had penetrated the 
transverse facial vein, and that the blood in the right cavity of the 
heart had been immediately coagulated." Several cases have occurred 
on the Continent, and at least one in England, in which an injection 
of the perchloride has resulted in death by peritonitis, caused by the 
passage of a portion of the injection through the Fallopian tube. It is 
not to be forgotten that a similar result has followed the injection of 
fluids which are comparatively innocuous; but the possibility of such 
a result must, under no circumstances, be lost sight of. Forcible in- 
jection of the uterine cavity should never be attempted. Were it 
possible thoroughly to sponge the inner surface of the uterus in an 
efficient manner, this, no doubt would be preferable; but, as it would 
be all but impossible thus to bring the styptic solution into actual 
contact with the bleeding surface, some other means must be adopted. 
We are ignorant, it must be remembered, of the extent, or even the 
exact site of the surface from which the blood flows ; and, moreover, 
the cavity is so occupied with fluid and clotted blood, that we could 
not hope, by any mere process of sponging the actual surface of the 
mucous membrane, effectually to reach it. It would be necessary there- 
fore, as a preliminary measure, to wash out the uterus. Dr. Barnes 
says, however, that the conditions inseparable from a recent delivery, 
are a relaxed and patent condition of the os, which would readily admit 
of an escape into the vagina of any fluid injected in excess, so that the 
conditions are, in all respects, different from what has obtained inmost 
of the fatal instances recorded where injection has been practiced in an 
unimpregnated, and sometimes in a displaced, uterus. 

The following is the course recommended by Dr. Barnes: "You 
have the Higginson's syringe adapted with an uterine tube eight or 
nine inches long. Into a deep basin or shallow jug, pour a mixture of 
four ounces of the Liquor Ferri Perch loridi Fortior of the British Phar- 
macopoeia, and twelve ounces of water. The suction-tube of the syringe 
should reach to the bottom of the vessel. Pump through the delivery- 
tube two or three times to expel air, and insure the filling of the appa- 
ratus with the fluid before passing the uterine tube into the uterus. 
This, guided by the fingers of the left hand in the os uteri, should be 
passed up to the fundus. The injection should then be effected slowly 
and steadily, when you will find the fluid come back into the vagina 
mixed with coagula caused by the action of the fluid. The haemostatic 



XXIV.] TRANSFUSION. 415 

effect of the iron is produced in three ways : first, there is its direct 
action in coagulating the blood in the mouths of the vessels ; secondly, 
it acts as a poAverful astringent on the inner membrane of the uterus, 
strongly corrugating the surface, and thus constringing the mouths of 
the vessels ; thirdly, it often provokes some amount of contractile ac- 
tion of the muscular wall.' 7 All facts hitherto recorded seem to show, 
that we have in this an almost certain means of arresting uterine haemor- 
rhage, and Dr. Barnes insists that we should not defer its application 
too long, but resort to it without hesitation so soon as the ordinary 
means have received a fair trial. To wait until the vital powers are 
all but exhausted is certainly not giving the measure fair play ; but 
we apprehend we would only be justified in having recourse to such a 
procedure after the inefficacy of the other means has been thoroughly 
proved. 

[While there is no reason to doubt the efficiency of intra-uterine 
injections of the salts of iron in post-partum haemorrhage, and while 
the editor has seen the undiluted solution of the subsulphate used with- 
out any bad results, it cannot be denied that death has followed as a 
consequence of this method of treatment. For this reason Professor 
J. D. Trask, of Astoria, Long Island, in a paper published in the 
American Journal of Obstetrics for February, 1875, proposes to resort 
to intra-uterine injections of iodine, a measure originally proposed by 
M. Dupierris, of Havana, Cuba. M. Dupierris used half an ounce of 
the tincture of iodine diluted with an ounce of water. The condition of 
one of the patients whose history is related was certainly desperate, but 
the injection arrested the haemorrhage, and she finally recovered. — P.] 

In the course of any treatment which may be adopted, the general 
condition of the patient must of course receive earnest and continuous 
attention. The tendency to syncope must be combated by free stimu- 
lation by brandy, or by brandy and opium in combination, upon which, 
we confess, we place even more reliance. The frequently repeated ob- 
jection to opium in such cases is, that it is an agent which arrests uterine 
action, and therefore should be avoided when our object is exactly the 
contrary of this. And the objection holds good in so far as very large 
doses of opium are concerned; but if the dose be a moderate one, and 
combined with brandy or some other stimulant, it will always be 
found, if it acts at all, to act in a beneficial manner by rallying the 
patient from collapse, and either thus indirectly, or, it may be, by a 
more direct action, exciting the uterus to contract. The patient should 
always be placed upon her back with the pelvis high and the head low. 
The object of this is, not only to take advantage as far as is possible 
of the law of gravity as a haemostatic, but also to prevent that lateral 
bagging which is apt to take place in a relaxed uterus in the ordinary 
obstetrical position. Perfect rest and the recumbent posture are essen- 
tial, not only at the time of the haemorrhage, but for a considerable 
period thereafter. All danger does not cease with the arrestment of 
haemorrhage, or even with uterine contraction ; so that all these meas- 
ures must be insisted upon as safeguards against the recurrence of the 
peril with which the patient has been menaced. If it be a rule never 
to leave a patient, even after natural labor, without satisfying ourselves 



416 HEMORRHAGE AFTER DELIVERY. [CHAP. 

of the state of the uterus, how much more important must it be to 
watch the case in which haemorrhage has already caused us anxiety, 
and in which there is always a tendency to its return. Flooding may, 
in some instances, only become alarming when some time has elapsed 
after delivery ; but in most of them it will be found to be due to the 
retention within the womb of a portion of the placenta or membranes, 
or of clots which have prevented the thorough closure of the cavity. 

The tendency to syncope should, in all cases, be combated as far as 
is in our power ; nor, in a condition of great depression, should the 
patient be permitted to yield to the drowsiness which overtakes her, 
as this may prove as fatal as that which is the result of exposure to 
intense cold. The period of convalescence after severe haemorrhage is 
one which may require great care and management. There is, above 
all, a tendency to reaction, which may manifest itself in the form of 
precordial oppression, severe headache, and throbbing of the carotids, 
which injudicious treatment, either by alcoholic stimuli or improper 
articles of diet, may increase to symptoms more serious still. The 
bulk of the blood which has been removed must be replaced gradually, 
and with caution; and although the tolerance of stimulants is, during 
the haemorrhage and in presence of the symptoms of collapse, some- 
times truly marvellous — when brandy seems to produce no more effect 
on the brain than as much pure water — it is quite otherwise when the 
immediate danger has passed and the patient begins to rally. When 
the symptoms which indicate reaction subside, it may be necessary to 
persevere, by means of generous diet, old wine, and tonics, for many 
weeks, or even months, before the system recovers from the fearful 
state of depression into which it has been thrown. 

There are cases in which the arrest of haemorrhage, although com- 
plete, seems to have come too late, the recuperative forces of nature 
having been too seriously compromised. There remains in these cases 
a state of utter prostration in which there seems to be no tendency to 
rally, an irritable stomach, a continued tendency to syncope, and an 
apparent arrestment even of the function of assimilation. Such a state 
of matters can only terminate in one way, unless we can induce a rally, 
and the feeble hold which the patient has on life is gradually, but too 
surely relaxed. These are the cases in which, however desperate the 
circumstances, the operation of transfusion has succeeded, and we hope 
may often again succeed in rescuing the woman from the very jaws of 
death. This operation may be performed in various ways. The simplest 
process is that of immediate transfusion by some such simple apparatus 
as has been recommended by Dr. Aveling. 1 This is described as con- 
sisting " of two small silver tubes, to enter the vessels, and of an india- 
rubber tube by which they are united, and which has in its centre an 
elastic receptacle, holding about two drachms. It is without valves, 
and is simply a continuous pipe with an expanded portion in the 
middle. By its means, the vessels are, as it were, extended from one 
to the other, and a supplementary heart is added to regulate the cir- 
culation." Air is got rid of by first pumping water or a saline solu- 



Obstetrical Transactions, vol. vi, p. 133, 18G5. 



XXIV.] 



TRANSFUSION. 



417 



tion through it, and then seeing that it is quite full of blood before the 
tube is inserted into the recipient vein. 

In what has been called, in contradistinction from the other, the 
mediate process, the blood is first received in a vessel, in which it is 



Fig. 132. 




Dr. Avcling's apparatus for transfusion. 



kept at the proper temperature, and it is thence injected by means of a 
syringe, different varieties of which have been devised by Drs. Little, 
Richardson, and Graily Hewitt. In addition to the difficulty which 
attends the exclusion of air, another and no less formidable one con- 
sists in the tendency of the blood to rapid coagulation. It has been 
attempted, with the view of obviating the latter, to inject the defibri- 
nated blood only, the blood being received in an open vessel, rapidly 
stirred so as to promote coagulation, and then filtered. In a considera- 
ble number of cases, this process has been attended with successful 
results, sufficient at least to prove that the presence of fibrin is not 
essential ; but the preponderance of professional opinion is decidedly 
in favor of the " immediate" process. It has been proposed by Dr. 
Richardson, as a corollary to certain well-known experiments and con- 
clusions of his, to prevent coagulation by the mixture with the pure 
blood of ammonia in the proportion of three drops to each ounce; and 
with the same object in view, Dr. Braxton Hicks has used the phos- 
phate of soda. Some, arguing from the effects which have been known 
to follow the injection of a simple saline solution into the blood in the 
collapse of cholera, have advocated a similar mode of procedure in 
hemorrhagic collapse. The quantity to be introduced is much greater 
than when blood is used, and the following is the formula for the 
preparation of a solution which has been used by Dr. Little : 

Chloride of Sodium, 60 grains. 

Chloride of Potassium, ...... 6 " 

Phosphate of Soda, R " 

Carbonate of Soda, . . . . . . . 20 " 

Distilled Water, . 20 ounces. 

Perhaps the simple apparatus and process of Dr. Aveling is the best 
for ordinary purposes which has hitherto been devised, and from its 

27 



418 INVERSION OF THE UTERUS. [CHAP. 

simplicity of construction, it may be used by any one possessed of 
moderate dexterity. The operation has not been confined to cases of 
post-partum haemorrhage, but has also been employed in placenta 
previa, when the patient was too prostrated to survive delivery unless 
previously rallied. The successful performance of transfusion may, 
although followed by a rally, be again succeeded by renewed flagging 
of the circulation, and a recurrence of the original symptoms. In this 
case, it would be quite proper to repeat the injection. Professional 
attention has of late years been so thoroughly awakened to the im- 
portance of this procedure, that there exists in the minds of many 
experienced practitioners a strong hope, and some confidence, that 
obstetric mortality may in this way be in some measure reduced. 



CHAPTER XXV. 

INVERSION OF THE UTERUS. 

VARIETIES OF INVERSION:' THREE STAGES OF THE ORDINARY VARIETY — INVER- 
SION OF THE UNIMPREGNATED UTERUS — INVERSION USUALLY OCCURS DURING 
THE THIRD STAGE OF LABOR — CAUSES: DRAGGING UPON THE CORD: SHORT- 
NESS OF THE CORD: IRREGULAR CONTRACTION OF THE UTERUS — CONNECTION 
OF THIS ACCIDENT WITH HOUR-GLASS CONTRACTION — EFFECTS OF PARALYSIS 
OF THE FUNDUS — MECHANISM OF THE DISPLACEMENT — SYMPTOMS: PECULIAR 
VIOLENCE OF THE SHOCK: HAEMORRHAGE: ABSENCE OF TUMOR IN HYPOGAS- 
TRIUM — TO BE DISTINGUISHED FROM A FIBROUS POLYPUS — SENSIBILITY AND 
OCCASIONAL CONTRACTILITY OF THE TUMOR — MODES OF PROVING THE ABSENCE 
OF THE UTERUS FROM ITS NORMAL SITUATION — RECURRENCE OF HAEMORRHAGE 
IN CHRONIC INVERSION — TREATMENT: ORDINARY METHOD OF REPLACEMENT : 
MANAGEMENT OF THE PLACENTA IF STILL ADHERENT : MANAGEMENT OF MORE 
DIFFICULT CASES : COMPRESSION OF TUMOR : DEPAUL'S INSTRUMENT— CHRONIC 
INVERSION: MONTGOMERY'S METHOD OF REPOSITION: CONSTRICTION OF THE 
OS MUST BE OVERCOME: EFFECTS OF SUSTAINED ELASTIC PRESSURE — DIVISION 
OF THE stricture: REMOVAL BY THE ECRASEUR. 

Inversion of the Womb has already been referred to in the pre- 
ceding chapter as one of the causes of haemorrhage after delivery. 
There are, in addition to this, other circumstances, of no less impor- 
tance, which render the subject one demanding, at our hands, special 
and careful consideration. Although the accident is by no means of 
frequent occurrence, it is not to be supposed that, on that account, it is 
to be treated as one of minor consequence. On the contrary, it in- 
volves so many practical questions, and is, moreover, a subject in 
regard to which so much misapprehension has existed, and still exists, 
that it is necessary to devote somewhat more of space to its considera- 
tion than its importance might, in the first instance, seem to warrant. 

The idea essentially involved in the term " Inversion of the Womb" 



XXV.] 



VARIETIES OF INVERSION. 



419 



Fig. 133. 



is an abnormal condition of that organ, in which, in extreme cases, the 
whole organ is turned inside out. As has already been remarked, such 
a displacement, must, in becoming complete, pass through a variety of 
stages ; and as, at any one of these stages, the 
inversion may be arrested, it is possible to 
imagine an almost infinite number of varieties 
of inversion. We shall, however, only men- 
tion four. Of these, the first is not generally 
described, but is said by Dr. Matthews Dun- 
can to be " not rarely observed after delivery." 
The condition of the parts is as shown in this 
diagram (Fig. 133), and consists, therefore, in 
an inversion of the inferior segment of the 
uterus only. This variety, although, proba- 
bly, not uncommon, is of no great practical 
importance, as it will rectify itself without 
assistance. It is otherwise with the three 
varieties which are figured diagrammatically 
in Figs. 134, 135, 136. All these are, as 
will be observed at a glance, merely stages in 
the progress of the same accident, which is 

the true Inversio Uteri of authors, and which differs from the other 
and less important variety, in commencing at the fundus. It is quite 
possible that the variety represented in Fig. 133 might, as in the other 
case, terminate in complete inversion ; but the experience of all goes 
to show that the ordinary course is — first, one of Depression of the 
Fundus (Fig. 134); second, one of Partial (Fig. 135); and, third, one 




Partial inversion. (After 
Matthews Duncan.) 



Fig. 134. 



Fig. 135, 



Fig. 136. 






Successive stages of inversio uteri. 



of Complete Inversion (Fig. 136). In a stage more advanced still, 
the inverted womb may protrude from the vulva, — a condition which 
necessarily involves at least partial inversion of the vagina, which is 
dragged down by the womb. 

Although essentially one of the accidents of midwifery practice and 
usually occurring in the course of delivery, there are cases in which 
the uterus becomes inverted independently of the pregnant state. Most 



420 INVERSION OF THE UTERUS. [CHAP. 

of those are instances in which there is either a polypus within the 
cavity, or a fibroid growth in the walls of the uterus, which, by acting 
in a manner as foreign bodies, excite the organ to contractile and ex- 
pulsive action, terminating in inversion. It is a disputed point, 
whether inversion of the normal and unimpregnated uterus is, in any 
other circumstances, possible. On this point Dr. West says, " Inver- 
sion of the uterus, the turning of the organ inside out, is an accident 
clearly impossible in the natural condition of the unimpregnated 
woman, — it being obviously essential for its occurrence that the organ 
should have attained a certain size, and that its walls should be com- 
paratively yielding." This opinion is adopted by Matthews Duncan 
and others; but Dr. Tyler Smith believes, on the other hand, that the 
unimpregnated uterus may invert itself, under the influence of irregu- 
lar contraction. We are not aware that any case has been recorded in 
which the evidence of inversion, under such circumstances, is not open 
to doubt, more or less strong. At the same time, we must confess that 
we agree with Tyler Smith's conclusion. It is certainly true, as he 
says, "that the unimpregnated and virgin uterus, particularly under 
irritation, possesses more motor power than is generally attributed to 
it ;" and we can see no physiological reason which can warrant us in 
assuming such an inversion to be impossible. Many years ago, we 
had occasion to assist at the post-mortem examination of a young 
woman who had died of fever, and who had suffered previously to her 
death from severe flooding. The uterus was found completely in- 
verted, and of very little, if any, greater size than the normal unim- 
pregnated standard. There was neither polypus nor fibroid growth. 
This case corroborates strongly the assertion of Tyler Smith, and, at 
least, proves that previous enlargement of the organ, and a yielding 
condition of its walls, are not, as West supposed, essential. There 
cannot be the slightest doubt that the presence of a polypus, or of any- 
thing else, within the cavity of the uterus, must so far encourage inver- 
sion, both mechanically and physiologically. In the above case, there 
may have been a clot ; but, whether or no, it, and other cases of an 
allied nature, seem to show that inversion of the unimpregnated uterus, 
independent of polypus, or any other similar condition, may occur. 

Causes. — The occurrence of uterine inversion, coincident, as is to be 
feared, very frequently, with the practice of dragging upon the cord 
after the termination of the second stage of labor, has led not unnat- 
urally to a prevalent belief that this was the usual cause of the acci- 
dent in question ; and it has also been supposed to be due, in some 
instances, to spontaneous dragging by a funis which is either too short, 
or has been rendered so by twisting round some part of the child. 
According to these ideas, the uterus must be looked upon as a passive 
agent, the fundus or site of placental attachment being mechanically 
displaced in a direction downwards, and ultimately through the os and 
into the vagina. That a certain number of cases are thus produced, 
most observers will probably admit; but the conclusion arrived at by 
all who have paid, in recent times, most attention to the subject, is, 
that the importance of this, as a cause, has been in every way exagge- 
rated. A strong pull at the cord, while the uterus is in a state of 



XXV.] CAUSES. 421 

flaccidity or complete atony, may doubtless — and especially if the pla- 
centa be morbidly attached — at once turn the organ inside out. In- 
deed, if such flaccidity were the normal condition of this stage, it would 
be a matter of wonder that the accident should not invariably accom- 
pany every effort in this direction, did we not observe that nature here 
interposes her authority, and effectually guards the woman, as we shall 
see, from the effects of operative mismanagement. Nothing, as a mo- 
ment's reflection will show, is so certain, so effectual a safeguard 
against inversion, as regular and symmetrical contraction of the whole 
uterus. It is fortunate, therefore, that a very usual effect produced by 
pulling upon the cord is a contractile action of this nature, by which, 
for the time being, depression or introcession of any part of its walls is 
rendered impossible. Be it observed, however, that this observation 
applies to regular contraction only. 

The uterus does not, in every instance, follow the method of regular 
contraction. On the contrary, it not unfrequently is the seat of irregu- 
lar contractions, which affect certain portions only of the walls, while 
other parts are left in a temporary condition of relaxation or atony. 
One form of this has already been mentioned as a cause of retention of 
the placenta by what is familiarly known as " hour-glass" contraction 
of the uterus, and otherwise as " encysted placenta." It would seem 
as if, in the opinion of many, this was the only form of irregular uterine 
contraction, whereas there can be little doubt that an infinite variety of 
such irregularities may exist. It is, in fact, among such abnormal 
conditions that the true cause of ordinary cases of inversion is to be 
sought. Many of the older writers recognized the presence of such 
contractions as we now allude to; and one of the earliest observations 
in this direction was, that a frequent site of this localized inertia is that 
portion of the uterus upon which the placenta happens to be implanted. 
The important bearing w T hich this has upon the cause and mechanism 
of hour-glass contraction was clearly pointed out by Levret, although 
altogether overlooked by many subsequent writers. "The neck of the 
uterus/' says Madame Lachapelle, "is often inert, although the fundus 
is contracted ; sometimes the reverse happens, and it is then that the 
placenta, inclosed in the uterus, appears to be encysted in it." As the 
nature of these and other abnormal conditions of contraction is more 
exactly ascertained, the relation which they bear to inversion of the 
uterus comes into view. All modern observers agree in the observa- 
tion that a local uterine paralysis, involving, as a matter of course, 
more or less irregular contraction, occurs more frequently at or near 
the site of the placenta than in any other part of the uterus. As this 
is the part which, by its introcession or depression towards the centre 
of the uterine cavity, forms the first stage of inversion, the coincidence 
of the displacement with the site of local paralysis has drawn special at- 
tention to the fact. Rokitansky, in his work on Pathological Anatomy, 
says on this point : " We must here mention a very singular circum- 
stance, which may, on account of the consequent danger, become im- 
portant, and may even be misunderstood in post-mortem examinations; 
it is paralysis of the placental portion of the uterus, occurring at the 
same time that the surrounding parts go through the ordinary processes 



422 INVERSION OF THE UTERUS. [CHAP. 

of reduction. It induces a very peculiar appearance. The part which 
gave attachment to the placenta is forced into the cavity of the uterus 
by the contraction of the surrounding tissue, so as to project in the shape 
of a conical tumor, and a slight indentation is noticed at the correspond- 
ing point of the external uterine surface." Whether the words which 
we have placed in italics represent or not the real cause of the first stage 
of displacement is a question not as yet definitely settled. Matthews 
Duncan, in his essay on this subject, maintains that the uterus cannot 
itself effect introcession, and that it must, on that account, in every 
instance, be commenced by a force external to the uterus. In the case 
of dragging upon the cord, we have a force of this kind acting from 
below 7 ; and, as regards spontaneous inversion, he assumes that we have 
a cause of a similar nature acting from above in the mechanical condi- 
tions of the abdomen, which are called into play, and which take the 
effective form of what is familiarly known as " bearing-down" effort. 

Whatever may be the view entertained, as to the initiatory process 
by which spontaneous uterine inversion is effected, numerous authentic 
facts attest that such an occurrence takes place by the operation of 
causes which may be at once abnornal and spontaneous. So soon as 
the stage of depression has been established, as represented in Fig. 134, 
the further progress of the case admits of easy explanation. The 
analogy which at this stage exists between inversion and an ordinary 
case of " hour-glass" contraction has not failed to attract the attention 
of many of the more eminent writers on this subject. In both, we find 
the region of the fundus in an abnormal condition of atony, but the 
parts below are in a state of more or less efficient contraction. A 
stimulus to sustained and active contraction is afforded by the presence 
within the cavity of a tumor. " The annular contraction of the body 
of the uterus grasps," says Tyler Smith, " the introcedent fundus as it 
would a foreign body, and carries it downwards for expulsion through 
the os uteri, the os itself being at this time either in a state of inertia, 
or actively dilated, just as at the end of the second stage of labor. After 
the inverted uterus has passed through the dilated os uteri, this part 
of the organ becomes contracted, preventing reinversion from taking 
place. Thus there is, first, the depression of the fundus uteri, with 
annular or hour-glass contraction of the body of the uterus, and dilata- 
tion of the os uteri. Next, there is intussusception of the fundus by 
the body of the uterus. Lastly, complete inversion occurs, with con- 
traction of the os uteri upon the inverted organ. If we wished to 
describe this action in three words, they would be — introcession — intus- 
susception — inversion" (see Figs. 135, 136). 

It must not be supposed that, by thus supporting the doctrine of 
spontaneous inversion, the production of the accident by artificial or 
violent causes is ignored; still less, that any support is given by impli- 
cation to the improper practice of pulling upon the cord with the view 
of effecting separation of the placenta. It will be inferred from what 
has already been said, that there are two classes of cases, in one of 
/which the uterus is completely, and in the other partially paralyzed. 
Inertia, therefore, in some form or another, is an essential concomitant 
of all cases of inversion. In complete atony of the organ, uterine 



XXV.] SYMPTOMS. 423 

activity can take no part in the displacement, although bearing down 
or abdominal effort may ; but, in the other variety, where, as has been 
shown, local paralysis has its usual seat about the fundus, uterine effort 
is the efficient cause in all cases of spontaneous inversion, and in those 
in which the displacement is artificially produced, there is every reason 
to believe that there must be, so to speak, a consenting action on the 
part of the uterus, which then acts in unison with the force which is 
applied. If any further evidence were held to be necessary to establish 
the fact of such an occurrence, it is to be found in the instances which 
have been put on record of post-mortem inversion, which can only thus 
be satisfactorily explained. 

Symptoms. — Inversion generally takes place shortly after the birth 
of the child, and before the placenta has been expelled. The patient 
being thus under the immediate observation of the accoucheur at the 
moment of the occurrence of the accident, the first symptom which will 
in all probability attract his attention is a condition indicating shock, 
out of all proportion to the circumstances even of a lingering or exhaust- 
ing labor. The violence of the shock, and the disturbance of the 
nervous system which accompanies it, bear no relation to the degree of 
the inversion. We would naturally expect that, in the stage of depres- 
sion or introcession, the symptoms would not be so severe as in the 
more advanced stages ; but in respect of these latter, it has been ob- 
served that the amount of shock attendant upon intussusception and 
complete inversion is as great in the one case as in the other. The 
degree of constitutional disturbance depends, however, in a great meas- 
ure, upon the amount of haemorrhage, and this again upon the extent to 
which the placenta has become separated. In all cases in which com- 
plete separation of the placenta may have occurred, the haemorrhage is 
alarming, and may be so severe as to place the life of the patient within 
a few minutes in most imminent peril. But if the contraction of the 
cervix is firm, it may be by this in some measure controlled. 

The occurrence of such symptoms is accompanied by an unusual 
condition of parts, as examined through the abdominal walls. In the 
stage of depression we may feel the outline of the uterus, but it is no 
longer a spheroid, for its centre presents a cuplike depression which 
can be distinctly felt by the fingers. In the more advanced stage, 
however, the hard tumor which the uterus should in normal circum- 
stances form behind the pubes is absent, nor is there in its place any 
such condition of general tumidity as might indicate a flaccid organ 
distended with blood. The uterus has, in fact, passed beyond the reach 
of the finders in this direction. If we now make a vaginal examina- 
tion, the nature of the case is at once revealed. A firm rounded tumor 
is here felt, which may also protrude externally. If to this the placenta 
is still partially or entirely adherent, there is of course no possibility 
of error, but when the placenta has become separated, no inconsiderable 
perplexity and difficulty may arise. 

The distinction between a fibroid polypus and a partial inversion has 
already been alluded to under the head of post-partum haemorrhage. 
In addition to what was then remarked, we need only observe here 
that, in some cases, the sense of touch affords little reliable information, 



424 INVERSION OF THE UTERUS. [CHAP. 

as there is in this respect such variety in the texture both of polypi and 
inverted uteri, that the most skilled observer could scarcely by this 
alone distinguish between the two. The really important point in 
diagnosis is this, that polypi, owing to the narrowness and length of 
the pedicle, can generally be moved much more freely, and may be 
twisted to a greater extent on their long axis without giving rise to any 
particular pain. Any attempt which may, on the other hand, be made 
to twist the tumor which is formed by an inverted uterus, is attended 
with considerable pain, and can, moreover, be effected only within the 
narrowest limits. If there is any inherent contractility in the tumor, 
this at once shows that it is the uterus. If the inversion is complete, 
the continuity of the vagina with the lateral walls of the tumor enables 
us by the finger to recognize the nature of the case; but when the 
intussuscepted fundus is tightly grasped by the os and its diameter at 
this point thereby reduced, the resemblance to a fibroid polypus is 
greatest, and it is here that the tests of immobility and sensibility may 
be most usefully applied. The nature of the case may be still more 
conclusively demonstrated by such modes of examination as may prove 
the absence of the uterus from its normal situation. On this point, 
Barnes recommends that we should pass one or two fingers into the 
vagina to the root of the tumor, and then press down the fingers of the 
other hand behind the symphysis. If in doing this we can make the 
fingers meet, and feel from the outside the funnel of the inverted uterus, 
our diagnosis will be confirmed. Or, again, we may pass a finger into 
the rectum so as to get its point above the root of the tumor, and then 
pass a sound into the bladder, with its point turned backwards, so 
as to meet the finger in the rectum, which, if it can be effected, will 
equally show that the uterus is absent from its usual situation, and 
consequently, by inference, that the tumor in the vagina is the uterus. 

Simple prolapsus or procidentia, when occurring immediately after 
labor, may also be mistaken on a careless or cursory examination for 
inversion, but more careful observation will at once in such cases dis- 
close the real nature of the case, as soon as the depression correspond- 
ing to the os and the orifice itself is recognized in the centre of the pro- 
jecting tumor. 

The symptoms above enumerated are those of an ordinary case of 
uterine inversion incurring in the course of labor, and do not of course, 
apply in all respects to the other and rarer varieties. Assuming it for 
the moment as proved, that inversion of the unimpregnated organ is a 
possible occurrence, it is undoubtedly so rare that little or nothing 
can be said as to its symptoms; but we may assume that haemorrhage, 
pain, and nervous shock will be among them, and that the diagnosis 
may be unusually difficult. There may be cases again, in which the 
presence of a polypus is established, and yet inversion may occur, the 
two conditions thus coexisting, although the former has in all proba- 
bility been the direct cause of the latter. There are yet other instances 
in which inversion may succeed delivery, and yet not follow so closely 
upon it as under ordinary circumstances it does. Possibly, in such the 
initiatory stage of depression has alone been produced during labor, and 
this again has been transformed into one or other of the more advanced 



XXV.] TREATMENT. 425 

stages by irregular contractions, or modifications of what are known as 
after-pains. It would appear as if occasionally the symptoms, at the 
time of the inversion, were not so marked as usual ; for there can be 
no doubt that the accident has sometimes been altogether overlooked 
at the time of labor, and only discovered long after. When the woman 
recovers from the immediate effects of inversion, she may regain her 
health and strength as if nothing ailed her, and be able to follow her 
ordinary avocations. But, in such cases, the original symptom of 
haemorrhage will, sooner or later, return, and, by its periodic recur- 
rence — corresponding often, as might be anticipated, to catamenial 
periods — saps the strength and undermines the health of the patient. 
These constitute cases of Chronic Inversion. 

Treatment. — Whatever the stage may be at which inversion of the 
uterus is recognized, our duty is to reduce the dislocation of the fundus 
without unnecessary delay. If we were fortunate enough to discover 
what has happened immediately, there would probably be but little 
difficulty in effecting the reposition, as we would then find the os in a 
state of relaxation. This period is, however, of brief duration, and is* 
followed by contraction of the os, which grasps the organ firmly, and 
in this way adds very greatly to the difficulty of the operation. 

If the placenta is still adherent, it is a question whether we should 
at once separate it. The advantage of the procedure is, that the fundus 
will undoubtedly be more easily reduced than when its bulk is increased 
by the presence in its immediate neighborhood of the mass of the pla- 
centa ; while, on the other hand, the obvious disadvantage of separa- 
tion is to encourage haemorrhage by rupturing the utcro-placental 
vessels. Both methods of treatment have been adopted, but it is cer- 
tain that neither of them can be held as appropriate to all cases. Re- 
position along with the placenta is, in fact, only applicable to those 
cases in which the os is relaxed, and is all but impracticable in the 
other class of cases, where we may find it difficult enough to return the 
fundus alone through the stricture formed by the os. Practically, the 
question may be said to stand thus : return the placenta if you can, or 
attempt to return it, if you can see a reasonable prospect of doing so 
without the exercise of undue force ; otherwise, separate the placenta 
at once, and do not waste time which may be of inestimable value in 
the interests of your patient. To remove the placenta from its attach- 
ments, insert the finger beneath the edge, and gradually strip it from 
the entire surface to which it is adherent. The diminished size, and 
at least partially contracted condition of the uterus, lessen to a con- 
siderable extent the danger which we would naturally anticipate from 
haemorrhage ; but the risk is still sufficient to render it imperative 
that we should make no delay at this stage, but proceed at once to the 
reduction. 

The method which is usually recommended is to bring the points of 
the fingers together, and to apply the apex of the cone thus formed 
firmly to the centre of the displaced fundus, which is by this means to 
be steadily pushed upwards in the axis of the pelvis, so as to carry the 
fundus through the ring formed by the contracted os. Due caution 
must, of course, be exercised in regard to the amount of force which is 



426 INVERSION OF THE UTERUS. [CHAP. 

employed, as it is possible by violence to inflict very considerable injury 
upon the uterine tissue. So soon as the fundus passes through the os 
in the process of rein version, it must be followed upwards by the 
finger, to render the operation complete. While this is being effected, 
the organ is to be steadied, as far as is practicable, by the hand which is 
placed upon the abdomen, and the operator must, in addition to this, 
be careful to direct the force to one side or other, so as to avoid the 
sacral promontory. 

When a certain time, even a single hour, has elapsed since the dis- 
placement has taken place, the difficulties of the operation may be 
considerably increased ; and when this has extended to days, it will 
naturally become more difficult still. The effect of the strangulation 
of the neck of ihe tumor is to cause general tumefaction of the parts 
beneath, so that it will often be necessary to compress the organ from 
side to side, in order to curtail its dimensions in that direction before 
attempting actual reduction. By this manoeuvre a difficulty, which 
may at first seem insuperable, will sometimes be overcome. By the 
ordinary procedure, by means of the fingers, the reposition of the uterus 
has been found by some operators to be so difficult that instruments 
have been used which, being of less bulk, are presumed to offer certain 
mechanical advantages. Of such a nature is the baton repoussoir of 
Depaul ; but to this it may fairly be objected that the gain is probably 
more than counterbalanced by increased risk ; and it must be confessed, 
in this, as in many other operations in midwifery, that the more expe- 
rienced and skilful the accoucheur, the more does he prefer his fingers 
to mechanical aids, however ingenious. 

When the fundus has passed to a certain distance within the os, it 
has very frequently been observed that the same muscular action of the 
uterus which originally contributed to the dislocation of the organ now 
comes into play as an auxiliary to reposition, and it is not uncommonly 
observed that the ultimate complete restitution of the fundus is effected 
by a sudden jerk or snap, which is often quite audible to the bystanders. 
In those instances, however, in which inertia of the organ is persistent, 
it will be necessary to pass the hand quite within the cavity, until we 
are convinced that its anatomical relations are completely re-established. 
Nor is it proper, at this moment, and at once, to withdraw the hand. 
We should rather act here as we would do in a case of encysted pla- 
centa, or of post-partum haemorrhage, in which the hand is introduced 
for the removal of the uterine contents ; and it is, therefore, advisable 
to allow it to remain in contact with the uterine walls, and to act with 
the other hand, in concert w T ith it, through the abdominal walls, so as 
to excite the organ to efficient and symmetrical contraction, which is a 
safeguard both against haemorrhage and a repetition of the displace- 
ment. 

There is another class of cases, in which the difficulties are still more 
formidable than any which have hitherto been described. It may be 
assumed that the longer the standing of the case the more serious will 
be the obstacles to reduction, until it reaches the condition to which 
the name Chronic Inversion has been given. Where, it may be asked, 
may we assume acute inversion to end and chronic inversion to begin? 



XXV.] CHRONIC INVERSION. 427 

The only rational reply to this question with which we are acquainted, 
is that which is given by Dr. Barnes in his recent work : " I would 
distinguish the cases in this way : inversion is recent so long as the 
physiological process of involution of the uterine tissues is going on. 
When this process is complete, and the uterus has returned to its ordi- 
nary condition, the inversion is chronic." In all cases of unusual 
difficulty, whether recent or chronic, the process of taxis, recommended 
by Montgomery, McClintock, and other distinguished practitioners of 
the Irish School, may be attempted. The idea here is to regard the 
inversion as a hernia, and to replace that part first which comes down 
last. The neck of the tumor is to be firmly grasped, and pushed up- 
wards, continuous pressure being thus maintained upon the contracted 
os. If the cervix can be insinuated within the lips of the os as the 
latter relaxes, the rest of the tumor is to be treated in a similar way, 
until at last the fundus returns to its place in the usual sudden manner. 

It was at one time generally supposed that, when a few hours had 
been permitted to elapse, inversion might be looked upon as irreducible. 
The results of modern practice have, however, clearly demonstrated 
that such an idea is quite untenable; and it may now be confidently 
asserted, that no condition short of inflammatory adhesion of the parts 
will warrant such a conclusion, whatever the duration of the case may 
be. The great point to be kept before us, and against which all opera- 
tive effort is to be directed, is the contracted state of the os. However 
hopeless, therefore, on a cursory examination, the case may seem to be, 
we may be confident that sustained effort will, in the end, overcome the 
resistance. But, to be effectual, it must be continuous; and we have 
only to reflect upon the fact that Tyler Smith succeeded thus in reducing 
an inverted uterus of ten years' standing, and that a number of cases 
are on record of a similar kind, to encourage us, even under the most 
unpromising circumstances, in diligent and untiring effort. 

Pressure effected by means of the hand of the operator, although 
perfectly safe, cannot be maintained for a sufficiently long period, and 
is thus inapplicable to the class of cases which we are now considering. 
The very obvious danger which would attend the use of any solid 
material, has led to the employment of air or water bags, which are to 
be introduced into the vagina, and gradually distended. This elastic 
pressure is, when properly applied, perfectly safe, and can usually be 
borne by the woman without much uneasiness. In Tyler Smith's case, 
above referred to, the details of which will be found in the Medico- 
Chirurgical Transactions for 1858, the pressure was kept up for more 
than a week; and, in many other cases, a similar process has been 
attended with equally satisfactory results. The mode of action in 
these seems to be that continuous although indirect pressure is thus 
brought to bear upon the os. At first, this is as ineffectual, or even 
more so, than the previous efforts, which have already been made with 
the view of effecting reduction by manual interference ; but, in the end, 
the long-continued pressure wears out the spasm, the os yields, and 
reinversion occurs. 

In those instances in which it is said that the organ has been spon- 
taneously restored to its normal condition, as in a case narrated by 



428 INVERSION OF THE UTERUS. [CHAP. 

Baudelocque, it is certain that a spontaneous relaxation of the os must 
have occurred, and it is probable that, along with this, the inverted 
organ had been subjected to some pressure in its new situation from 
permanent or temporary causes. The theory that a spontaneous re- 
duction may take place in consequence of tonic contraction of the Fal- 
lopian tubes and of the broad or round ligaments, appears to us to be 
in the highest degree improbable. The condition, of all others, essential 
to replacement is, we repeat, relaxation of the os. There may be cases, 
however, in which even sustained elastic pressure may fail to effect the 
object which we have in view, although we have every reason to believe 
that such must be of rare occurrence. But, even under such circum- 
stances, our resources are far from being exhausted, and various methods 
have been adopted for overcoming the difficulty in individual cases, 
which it would be impossible to describe here. The idea of section of 
the constriction must have often suggested itself; but Dr. Barnes was 
probably the first to carry a case to a successful termination by this 
operation. 1 The proceeding, as described by him, is as follows : " Draw 
down the uterine tumor by means of a loop of tape slung round the 
body, so as to put the neck of the tumor upon the stretch ; then, with 
a bistoury, make a longitudinal incision about half an inch long, and 
a quarter of an inch deep, on either side, into the constricting os ; then 
reapply the elastic pressure. Next day, try the taxis, and reapply 
the elastic pressure if necessary. Elastic pressure alone, or aided by 
this operation, will, I am convinced, overcome every case of inversion, 
except when fixed by inflammatory adhesions." Another, and proba- 
bly a safer, process has also been suggested, by which the incisions in 
the os are increased in number, but made much more superficial. 

Cases have been met with in which menstruation has gone on regu- 
larly from the surface of an inverted uterus ; and, indeed, observation 
of such instances has thrown some light upon the source of the men- 
strual discharge. In such cases, leucorrhoea, and the presence of a 
tumor within the vagina, may be the only symptoms, but the almost 
invariable rule is repeated flooding, and that to such an extent as to 
bring the patient into a condition of immediate clanger. Failing all the 
means already detailed — in the practice of which it has been assumed 
that full advantage has been taken of chloroform, an invaluable agent 
in all cases of uterine spasm — is there any other method which we may 
adopt for the relief of a woman who may be dying before our eyes from 
the effects of this accident? 

The only possible remedy in such a case is removal of the inverted 
uterus, as this alone can be expected effectually to check the haemor- 
rhage. The objections to such a procedure are sufficiently manifest; 
for not only is the case one of mutilation, by which the woman is un- 
sexed, but it is one the immediate risk of which is very great. Still, 
the operation has been repeatedly performed with success, and the 
woman has enjoyed perfect health for many years thereafter. In the 
only case which has come under our observation, the patient, who was 
operated upon about nine years ago, is still alive, and in perfect health ; 

1 Medico-Chirurgical Transactions, 1869. 



XXV.] 



REMOVAL BY THE ECRASEUR. 



429 



and it is worth remarking, in addition, that she has never menstruated 
since, but that the menstrual molimen is apparently relieved by peri- 
odical or vicarious leucorrhoea. If, therefore, the doom of a patient 
seems fixed if we decline to interfere, we should have no hesitation in 
resorting to a measure so extreme as the removal of the organ ; and, 
of course, at the present day the operator would select the ecraseur in 
preference to the older methods of ligature or excision. The best in- 
strument for the purpose is the wire-rope ecraseur of Braxton Hicks, 
which may be used either with fine wire twisted into a rope as recom- 
mended by the inventor, or with a single strong wire as is recommended 
by Barnes. The responsibility which attaches to an operation such as 
this cannot fail to w r eigh upon the operator ; and he will, therefore, at 
once recognize the necessity, before finally committing himself to this 
course, of making himself sure on two points : first, as to the accuracy 
of his diagnosis; and, second, that the tumor is beyond all doubt irre- 
ducible. Until we can form a confident opinion in regard to both 
these matters, we cannot, in any case, conscientiously proceed to ope- 
ration ; and it must also be borne in mind that the more perfectly has 
our knowledge of the accident become developed, the more completely 
has the operation for removal of the organ fallen into disuse and 
disfavor. 

[Extirpation of the uterus under these circumstances is frequently 
fatal. About one-third of all the cases end in death. It is besides a 
mutilation, from which the patient and her surgeon naturally revolt. 
Prof. T. G. Thomas has proposed and successfully practiced another 



Fig. 137. 




Thomas's method of reducing chronic inversion. (After Thomas.) 



method of cure in a very obstinate case of chronic inversion, in which 
Professors Miller of Kentucky, and Parvin of Indiana, as well as him- 
self had failed in effecting reduction after prolonged and repeated efforts. 
Under these circumstances Prof. Thomas proposed to reduce the 
displacement by making an incision in the abdominal wall, and stretch- 



430 RUPTURE OF THE UTERUS. [CHAP. 

ing the cervical constriction. For this purpose the patient is to be 
thoroughly etherized, when an assistant passes his hand into the vagina, 
and seizing the inverted fundus, lifts it up so that the cup-shaped de- 
pression can be felt against the abdominal wall. An incision about 
two inches long is then made in the median line; all the precautions 
recommended by ovariotomists being carefully observed, so that no 
blood is admitted into the peritoneal cavity. The peritoneum being 
opened, the operator then replaces the hand of his assistant with his 
own in the vagina, as is shown in the figure. He then stretches the 
constricted cervical ring with an instrument resembling a glove- 
stretcher. After this is completely dilated, the inversion is to be re- 
duced by one of the various methods of taxis. — P.] 



CHAPTER XXVI. 

KUPTTJKE OF THE UTERUS. 

RUPTURE DURING PRKQNANCY — RUPTURE DURING LABOR— PARTI AL OR INCOM- 
PLETE RUPTURE — SITE, EXTENT, AND DIRECTION OF THE LACERATION — REASON 
OF THE COMPARATIVE FREQUENCY OF CERVICAL RUPTURE — IS RUPTURE LESS 
COMMON IN PRIMIPAR.E ? — EFFECT OF THE DURATION OF LABOR — CAUSES — A. 
MECHANICAL : SEX ; PELVIC DEFORMITY; FAULTY PRESENTATION ; PRESS URE 
UPON THE CERVIX ; OPERATIVE VIOLENCE; ERGOT; VIOLENT UTERINE ACTION 
— B. REFLEX: EXCITEMENT OF CERVIX, ETC. — C. PATHOLOGICAL: CANCER; 
RIGIDITY OF THE OS; THINNING OR PARTIAL ATROPHY; SOFTENING; FATTY 
DEGENERATION — SYMPTOMS — PREMONITORY: LOCALIZED PAIN INCREASED 
DURING LABOR — SIGNS OF RUPTURE: PAIN: HEMORRHAGE ; SHOCK; RECESSION 
OF THE PRESENTING PART — LACERATIONS INVOLVING THE VAGINA— TR EAT- 
MENT — PREVENTIVE MEASURES: DELIVERY BY THE FORCEPS OR BY PERFORA- 
TION — EXTRACTION OF THE PLACENTA — HERNIA OF THE INTESTINE — IF FCETUS 
HAS ESCAPED INTO THE PKRITONEAL CAVITY, TURNING RECOMMENDED: GAS- 
TROTOMY IS, HOWEVER, TO BE PREF ERRED— FURTHER MANAGEMENT OF THE 
CASE — TREATMENT OF RUPTURE OF THE UTERUS IN VARIOUS STAGES OF 
PREGNANCY. 

Rupture of the Uterus, at all times one of the most appalling acci- 
dents of midwifery, is also the most fatal ; and is the more terrible, as 
in many cases it can neither be foreseen nor averted. The elaborate 
statistics for which we are indebted to Dr. Churchill, show the acci- 
dent to have occurred in 85 out of 113,138 cases of labor — about 1 in 
1331. Although rupture almost invariably occurs in the course of 
labor, it is not always so, as a certain number of well-authenticated 
cases have been put on record, in which rupture occurred at various 
periods in the course of pregnancy, in the absence of any uterine ac- 
tion whatever. Some of these cases have been the result of violence, 



XXVI.] PARTIAL RUPTURE. 431 

and a considerable number seem to have followed over-exertion of some 
kind. But there are others in which no such cause can have been in 
operation, as in a case published in the Medical Repository, by Mr. 
Scott of Bromley, in which a woman in the sixth month, was awakened 
from sleep by a sudden pain about the umbilicus, which was soon suc- 
ceeded by collapse and death. On examination after death, a rupture 
was discovered at the fundus, through which the foetus, enveloped in its 
membranes, had escaped into the abdominal cavity. It would proba- 
bly be impossible, in many of these cases, to distinguish between this 
accident and rupture of the sac of an extra-uterine pregnancy, as the 
symptoms are, in the two cases, almost identical. The very rarity of 
spontaneous rupture has not unfrequently given rise to suspicion of 
foul play in such cases, and the question has, therefore, a medico-legal 
significance, in reference chiefly to criminal abortion; but there will 
probably be little difficulty in recognizing a spontaneous rupture at 
this stage, as it is generally at the fundus, while criminal injuries are 
more frequently discovered in the region of the os and cervix. Be- 
sides, the nature of the injury is so different, that the appearance of 
a spontaneous rent and a violent laceration could scarcely be mis- 
taken ; and, moreover, there often is to be found, as the cause of these 
ruptures, a diseased condition of the structures of the womb. Rup- 
tures during the course of pregnancy may occur as early as the third 
month, but are more frequent, the more advanced is the development 
of the foetus. 

By far the greater number of cases occur during labor, and it is to 
these that attention must be more particularly directed. The lacera- 
tion in these cases generally involves the entire thickness of the uterine 
walls, but there are exceptions to this rule. In some, the rent is found 
to have extended through the mucous membrane and proper tissue of 
the uterus, and to have been arrested by the peritoneum, which remains 
intact. The mobility and distensibility of the peritoneum upon the 
subjacent uterine tissue in some measure encourages this ; and it is, 
therefore, at the lower portion, where the connection of the peritoneum 
is looser, that this has been more frequently observed. The result of 
such cases, although often fatal, is not so much to be despaired of as 
when the laceration is complete ; but a very probable result would be 
the effusion of blood between the peritoneum and the tissues beneath, 
and the consequent formation of periuterine hematocele. In many of 
these instances, it is most likely that the fact of laceration is not recog- 
nized at all at the time of its occurrence. Another rare variety of rup- 
ture consists in numerous fissured lacerations of the external surface 
of the tissue proper of the uterus, immediately beneath the peritoneum, 
which may give rise, as in the other case, to subperitoneal haemor- 
rhage ; while in other instances, the peritoneum itself is the only part 
which is lacerated, the uterine tissues escaping altogether. 

Any part of the uterus may be the seat of laceration, while the rent 
in the tissues may take any direction, and, in extent, may be limited 
only by the size of the organ itself. It may thus be either longitudinal 
or transverse ; and may, in the first case, correspond to the entire length 
of the uterus, and, in the latter, the laceration may extend completely 



432 RUPTURE OF THE UTERUS. [CHAP. 

around the uterus, thus dividing it into two. Both of these are extreme 
cases : the rent is generally much more limited in extent. Considerably 
more than half of all the ruptures at the full time occur in the region 
of the cervix, generally at that part which marks the junction between 
the uterus and the vagina. Next in point of frequency comes the body ; 
and last of all, the fundus, which is, as we have seen, the site preferred 
in early pregnancy. One of the most remarkable monographs on this 
subject is one which was published, in 1848, in the American Journal 
of Medical Science, by Dr. James D. Trask, and is based on an analy- 
sis of over four hundred cases. The following represents the propor- 
tion of cases in the various situations named, as deduced from his sta- 
tistics : 

Ruptures of the cervix, ..... 55 per cent. 
" " body, . . . • . . .36 " 
" " fundus, 9 » 

The reason of the comparative frequency of rupture at the cervix is 
afforded by a moment's consideration of the mechanism of the dilata- 
tion of the os, which has been fully detailed in reference to the prog- 
ress of the first stage of labor. The os, as was explained, is dilated 
by the combined action of the longitudinal fibres of the uterus and the 
bag of waters, or, in the absence of the latter, by the presenting part 
of the child ; so that we cannot wonder that the usual seat of rupture 
is where the greatest amount of force is brought to bear. Trifling rup- 
tures of the vaginal portion of the cervix, commencing at its margin, 
are among the most common of the minor accidents of midwifery. 
But, even when lacerations of this part are more extensive, the rent 
does not necessarily involve the peritoneum, so that the gravity of the 
case will depend chiefly upon whether or not that membrane is injured. 
In some rare instances, the laceration extends into the bladder, and in 
others, rarer still, the whole vaginal portion of the cervix has been 
separated, in the form of a ring, which has been born with the child. 
Lacerations of the cervix alone are very common, and generally take 
a vertical direction. They are said to occur more frequently on the 
left than on the right side. 

It was at one time generally supposed, and it is even now stated by 
many writers, that there is less liability to rupture in first than in sub- 
sequent pregnancies. A more correct observation of such statistics as 
bear on that subject, — among which those of Churchill and Trask are 
best known, — shows that this is not the case, but that there is, if any- 
thing, a preponderance of primiparous cases. The error has arisen 
from comparing first with all other labors ; but, if we compare first 
with second, third, fourth, and so on, individually, but not collectively, 
the result will be found to be as we have said. Another view, all but 
universally held, was that the accident was a common result of pro- 
tracted labor; and it is, indeed, not unnatural to suppose that this 
should be the case ; but there is, perhaps, no one point which is brought 
out more strikingly in Dr. Trask's cases than that the actual duration of 
labor has little or nothing to do with it. In 104 out of 147 cases rup- 
ture occurred within twenty-four hours of the commencement of labor. 



XXVI.] CAUSES. 433 

It must, however, be remembered that the usual course of a protracted 
case is failure of the pains ; so that, although we may fairly assume that 
long-continued effort would endanger tissues weakened by exhaustion, 
nature here arrests the pains, and thus interposes for the protection of 
the parts, vigorous action being only restored when she has had time 
to recruit her exhausted powers. 

Causes. — Whatever views may be entertained in regard to the two 
conditions above alluded to, there can be no doubt that anything which 
mechanically impedes the course of labor, is an undoubted cause of rup- 
ture of the uterus. The sex of the child thus plays, as might be ex- 
pected, an important part, as is shown by the statistics of the Dublin 
Lying-in Hospital, extending over a long period, from which it would 
appear that, in nearly 70 per cent, of all the cases of rupture, the sex 
was male. Trask's cases show, no less clearly, that pelvic deformity, 
or disproportion is another important cause, which had been proved to 
exist in 74.74 per cent, of his cases. For the same reason, faulty pres- 
entations, which are an impediment to labor, may be the direct cause 
of uterine rupture ; thus, in 303 cases given by Trask, of all presenta- 
tions, 16 were presentations of the shoulder. Forcible compression of 
the neck of the womb between the head of the child and the pelvic 
walls is supposed by Dr. Murphy to play an important part in inducing 
rupture of the womb, so that if it is pinched anteriorly against the ilio- 
pecti neal line, or posteriorly upon the promontory of the sacrum, ante- 
rior or posterior lacerations of the cervix are to be explained by the 
mechanical action of the fundus and the longitudinal fibres. 

Although we have every reason to believe that the more accurate 
knowledge of modern times has had a marked effect upon the results 
of modern practice, it must still be admitted that operative violence 
cannot be overlooked as a cause of rupture of the uterus. We do not 
here refer to such cases as occur in consequence of causes of a patho- 
logical nature, to which we shall again advert, where the accoucheur is 
often unjustly blamed ; but to those in which errors of judgment, or 
rashness in operative procedure, lead to this disastrous result. The 
most common of all midwifery operations, for example, may, in any 
case, be attended with extensive laceration ; for, if we apply the for- 
ceps -without due consideration, and careful observation of the state of 
the os, we may readily rend those tissues and destroy our patient. In 
the same way, clumsy manipulation in turning may, at any stage of 
that operation, in a moment plunge a satisfactory case into the category 
of hopelessness ; and so, in a hundred different ways, operative incom- 
petency may, in the attempt to shield the woman from danger, only 
precipitate her doom. The improper administration of ergot has, there 
is only too good reason to believe, been attended with a similar result 
in no insignificant number of cases, where that powerful drug has been 
given in tedious cases, without any reference whatever to the amount 
of mechanical resistance which has to be overcome ; and we rather 
think, that if the truth were known, — which for obvious reasons, is 
often withheld, — this, as a cause of uterine rupture, would stand promi- 
nently forward. Professor Bedford of New York has in his museum 
four wombs ruptured by the improper use of ergot. A preternatural 

28 



434 RUPTURE OF THE UTERUS. [CHAP. 

violence in the uterine contractions, even when associated with no 
marked resistance beyond what is perfectly normal, may also induce 
rupture by the actual impetuosity of the propulsive effort; but such 
cases, in the absence of morbid excitement of some kind, are probably 
very rare. When such morbid excitability does exist, it is astonish- 
ing, however, by what trifling causes violent action may be set up. It 
is by no means rare, that the slight irritation of the cervix which 
occurs in the course of an ordinary vaginal examination, arouses, by a 
reflex act, an amount of expulsive effort which may thus lead to rup- 
ture from a cause apparently so simple. Examples of this kind have 
been from time to time recorded, but cases which are centric in their 
origin are, undoubtedly, of far more frequent occurrence. Rupture 
has occasionally taken place, or has been extended, during straining 
at stool. 

Special attention has of late years been directed to certain patho- 
logical conditions, upon which there can be no doubt that rupture of 
the uterus occasionally depends. It is in these cases mainly that, in 
the most skilful hands, and with every possible attention, ruptures 
quite unexpectedly occur; and in such the practitioner may be cruelly 
and unjustly blamed. This, indeed, is by no means the least impor- 
tant of the considerations, which invest this part of the subject with a 
special interest. Some of the pathological conditions referred to also 
act, like the class of cases already mentioned, mechanically. Of this 
nature is cancer of the uterus, which generally attacks the os and 
cervix, and, unfortunately, in some instances, proves no bar to concep- 
tion. The nature of the disease, even when it has not passed to the 
more advanced stages, renders the affected tissues so undilatable, that 
laceration, under the influence of efficient uterine contraction, is almost 
inevitable ; and, in more extreme cases, the only safeguard may be 
Craniotomy or the Caesarian Section. Cases of extreme rigidity of 
the os and of the more external parts of the parturient canal, are by 
no means of rare occurrence in practice; and, if they should chance to 
be accompanied with, or complicated by, violent uterine effort, rup- 
ture may not unlikely occur. There are, however, other conditions in 
which laceration may take place quite independently of excessive mus- 
cular action, or even in the absence of such action, as the history of 
uterine ruptures during pregnancy and before labor seems to show, and 
the interesting researches of Dr. Murphy at the Dublin Lying-in Hos- 
pital, clearly demonstrate. " Thinning, or partial atrophy of the uterus, 
is not an unfrequent cause," says Dr. Murphy ; " four examples of this 

morbid change presented themselves to our notice When a 

change of this kind takes place, the symptoms are often very obscure. 
There may be a very severe laceration without any severe pains, or any 
of those prominent symptoms that often precede the accident. You can 
appreciate what would be the effect of ergot of rye, if it were given to 
increase pains rendered feeble from this morbid condition of the ute- 
rus. Softening is another pathological cause of laceration. The fibrous 
tissue seems to be the first tissue affected ; the mucous membrane may 
then be involved, but the peritoneum generally escapes. This morbid 
change may be only slight, affecting a few of the uterine fibres ; or it 



XXVI.] SYMPTOMS. 435 

may be extensive, converting the affected portion of the uterus into a 
putrid mass. Thus we have found a kind of aneurismal sac formed 
in the parietes of the uterus, in consequence of a partial rupture of the 
uterine fibres; no symptoms of laceration showed themselves during 
labor, nor did any appear until several hours afterwards, when the sac 
burst. In the same manner may be explained some of those obscure 
cases of sudden and fatal haemorrhage some days after delivery. Dr. 
Collins relates one in which the patient was seized with violent flood- 
ing on the fifth day after delivery. She died in an hour; and, on dis- 
section, it was discovered that a patch of the uterus, of about the size 
of a shilling, had given Avay, corresponding to the projection of the 
sacrum." 

Recent observations tend to show that that process of fatty degenera- 
tion which, as we have shown, is so essential a phenomenon of the 
normal process of involution (see Fig. 130, p. 371), sometimes takes 
place prematurely ; and, if so, it can be readily understood how such 
an occurrence — under the circumstances, of course, a pathological one — 
must essentially contribute to the risk of rupture. And there can be 
little doubt, as Tyler Smith observes, "that in cases where the uterus 
is feebly developed, or weakened by disease and exhausted action, the 
contractions of the abdominal muscles must contribute to the rupture 
of the organ, by urging the head or presenting part of the child 
through the os uteri." 

Symptoms. — The causes of rupture of the uterus being so various, it 
will excite no astonishment that the symptoms are far from being uni- 
form. Very violent and tetanic uterine contraction, under circum- 
stances which, for the time at least, render it impossible that labor 
can make much progress, will always excite our apprehension, and 
may seem to call for such means as we have at our command for mod- 
erating excessive action. But, the powers of nature are such that, even 
in the most unpromising circumstances, the dreaded result seldom en- 
sues. The significance of the premonitory symptoms is, however, 
greatly increased if, along with contractions of this nature, the woman 
complains of pain of an unusual intensity; and, if the site of such pain 
should correspond to a point where it had been complained of before 
labor, our fears will be proportionally increased. We cannot, how- 
ever, trust to premonitory symptoms. Indeed, in the great majority 
of cases, we have not even the benefit of such obscure signs as have 
been mentioned, and thus the climax of the case is attained while we 
are quite unprepared for a casualty so dreadful. 

As a general rule, the symptoms which denote actual rupture of the 
uterus are well marked. At the height of a pain, a sudden and excru- 
ciating pang may occur. This is sometimes accompanied with a snap 
which may be audible to the patient and even to those about her. The 
pain suddenly ceases, and is almost instantly followed by alarming 
prostration and shock, which is modified, more or less, by the charac- 
teristic symptoms of haemorrhage. This may be altogether internal, or 
may be indicated by a gush of blood from the vagina, according to the 
portion of the uterus which has been the seat of the rupture. The 
countenance becomes pallid, with a fearful expression of alarm and 



436 RUPTURE OF THE UTERUS. [CHAP. 

anxiety ; the face is bedewed with a clammy sweat, and the extremities 
and general surface become cold. The stomach ejects its contents, 
and at once throws off anything which may be swallowed; and it has 
sometimes been noticed, after protracted retching, that the matter vom- 
ited is of the color and appearance of coffee-grounds. The respiration 
becomes labored, and the pulse becomes rapid, feeble, irregular, and 
ultimately imperceptible. Simultaneously with these symptoms, the 
signs of the life of the foetus disappear. In some cases, the occurrence 
of rupture is not marked either by acute pain or by the other symp- 
toms above enumerated ; and the dangerous condition of the patient 
may only become apparent after a considerable period has elapsed, it 
may be hours, or even days. These are, for the most part, eases in 
which the rent is comparatively trifling in extent, and, if it should so 
happen that the entire thickness of the uterine tissues has not been in- 
volved, the ordinary expulsive contractions may go on, although prob- 
ably modified in degree. 

A very usual and significant symptom is recession of the head of the 
child, which may have come to press on the perineum, or even to dis- 
tend the vulva, and come distinctly into view. If, along with symp- 
toms such as have been described, the head suddenly recedes towards 
the upper part of the pelvis or passes beyond the reach of the finger, 
we can have little doubt as to the nature of the occurrence. We must 
here warn the young practitioner against an error into which he may 
fall, and which may cause him a considerable amount of unnecessary 
anxiety; for it not unfrequently happens, towards the termination of 
the second stage of labor, that the head suddenly and unexpectedly 
recedes, on the termination of a pain, to a much greater extent than is 
usual. Such an occurrence, however, need cause no alarm, as it is due 
to a mere temporary relaxation of the uterine walls, and is usually the 
forerunner of more efficient contractile efforts, under the influence of 
which the child is rapidly brought into the world. Complete recession 
of the presenting part, in rupture of the uterus, usually indicates that 
the child has passed or is passing through the uterine walls into the 
cavity of the abdomen, through the parietes of which the various parts 
of the child may be distinguished. In some cases, it would appear 
that the sudden cessation of pain was the only symptom of any im- 
portance, and it is worth remembering that this has been mistaken for 
inertia, and ergot administered. 

There is a class of cases which, although not strictly speaking rup- 
tures of the uterus, have so important an analogy to the latter that 
it seems proper to mention the subject here. These are ruptures or 
lacerations of the vagina. Lacerations of the lower part of the vagina 
are usually situated in its posterior wall, and, if they involve the super- 
ficial structures, they constitute the accident formerly described as Rup- 
ture of the Perineum. There are instances, however, in which the 
rupture of the tissue is very extensive in so far as the vagina is con- 
cerned, and in which, nevertheless, the external tissues of the perineum 
remain quite uninjured, such cases proving both tedious and trouble- 
some, although, as compared with rupture of the uterus, they are com- 
paratively trivial. The lacerations to which allusion is here more par- 



XXVI.] TREATMENT. 437 

ticularly made, in reference to uterine rupture, are those in which the 
head of the foetus, after passing the os, pinches in and compresses a zone 
of the vagina. The uterus in its contractile efforts pulls upon this 
fixed ring, precisely as happens when the cervix is similarly compressed, 
the result being a tear, which is transverse in its direction, and may 
extend circularly around the entire vagina. It is important to know 
that, in such cases, the whole of the uterus and the upper part of the 
vagina has been expelled by the natural efforts, which has given rise to 
the charge of malapraxis. It has been denied by some that the uterus 
could in this way rend its ligaments ; but recorded and perfectly au- 
thentic cases now clearly show that not only may the round and broad 
ligaments be torn asunder in this way, but that they may even be rup- 
tured as a mechanical effect of spontaneous inversion. Lacerations 
involving both vagina and uterus are not uncommon, and it is proba- 
bly difficult in some of these instances to determine for certain in which 
of the two textures the rupture has had its origin ; but there can be 
no doubt that lacerations, either of the cervix uteri or of the upper 
part of the vagina, must, in consequence of their intimate anatomical 
relations, be very apt to extend from the one to the other. A consid- 
erable haemorrhage could scarcely fail in such cases to be a prominent 
symptom. 

Treatment. — It is scarcely necessary to observe that, if there be any 
possible means whereby we may succeed in preventing this accident, 
such must necessarily be by far the most important point relative to 
treatment. But, unfortunately, the cases in which prevention is possi- 
ble are rare ; or, rather, the indications which demand preventive 
treatment are so obscure in their nature that it is difficult to tell, on 
the one hand, whether we are called upon to interfere, and, on the 
other, whether, having interfered, the safety of the patient may fairly 
be attributed to our conduct in the case. The latter point is perhaps 
the most difficult of all. We recognize, let us suppose, a serious me- 
chanical impediment to delivery, which coexists with violent and long- 
continued uterine effort, and which may seem to imperil the integrity 
of the uterine tissues. We operate, by the forceps, turning, or other- 
wise, and speedily relieve the patient; but when are we entitled to say 
that such prompt and decisive action on our part has actually averted 
a great calamity ? We may, indeed, be perfectly certain that a well- 
considered and definite plan of treatment, in accordance with which 
operative assistance is afforded or withheld, will reduce rupture of the 
uterus to a minimum, as is well shown by the statisticts of large lying- 
in hospitals, where this accident is one of those least frequently met 
with. It cannot, however, on the other hand, be doubtful that a need- 
less dread of rupture, which inexperience is certain to exaggerate, leads 
in some instances to operative interference, which may be perfectly un- 
necessary, although the operator does not fail to congratulate himself 
on a fortunate issue, which he fancies to be due to his prescience and 
skill. 

Apart from this, there are, however, certain conditions upon which 
an intelligent preventive treatment may be founded. The occurrence, 
for example, in the course of gestation, of acute pain, referable to some 



438 RUPTURE OF THE UTERUS. [CHAP. 

particular part of the uterus has often been known to precede rupture 
in the part affected, which is believed in these instances to have been 
the seat of local or limited metritis. Should any suspicion, therefore, 
of this be entertained, it will be proper to adopt such means as may 
seem suitable with the view of subduing the morbid action which is 
assumed to exist. One, and by no means the least important, of the 
objects which the accoucheur has in view in inducing premature labor 
in cases in which there must be disproportion of parts at the full time, 
is to avert the danger of rupture which fruitless uterine effort might in 
any case produce. And he will, in like manner, feel himself impelled 
to prompt and energetic action, when the expulsive effort of the uterus 
is morbidly in excess. In some of these cases, the contractions attain 
a tetanic violence, which seems at every moment to imperil the integrity 
of the uterine tissues ; and, if the period should not have arrived at 
which we may assist delivery by artificial means, we must then have 
recourse to such treatment as may subdue this violence, — of which 
opium, chloroform, and chloral hydrate are, in these days, the most 
familiar examples. In certain cases of extreme urgency it may be 
necessary to enlarge the orifice of the vagina by lateral incision of the 
perineum ; and, if we are certain that the child is dead, and it is 
making but slow progress under very violent uterine propulsion, we 
are justified in lessening the bulk of the head by the operation of 
craniotomy. In so far as the forceps is concerned — and the remark 
applies with still greater force to turning — we must not be astonished 
if any attempt at operative assistance should excite the organ to more 
violent contraction still, and thus defeat its own object. What con- 
stitutes morbid or excessive uterine action can of course only be learned 
by experience. 

The treatment of actual rupture, however desperate the circumstances 
may seem, calls for every possible attention, not only in the interests of 
the child — which may often be saved — but in that of the mother, who 
may, even in unpromising cases, rally from the effects of the injury and 
ultimately recover. We must not, therefore, accept the dictum of 
Smellie, that the accident is an absolutely hopeless one. All the best 
authorities are agreed that a speedy removal of the child affords the 
mother the best chance even when, the child being dead, this is done 
without any reference whatever to its condition other than considered 
as a foreign body. If the head of the child is still in the pelvic cavity, 
and thus within reach, it may be possible, although very rarely, to grasp 
and deliver it by the forceps ; and, it need scarcely be said, that if this 
can easily be done, it ought to be preferred as the method which is at 
once easiest and safest. As, however, in a large proportion of such 
cases, rupture is associated with more or less of pelvic disproportion, 
the usual practice is to perforate, and then to extract by the crotchet or 
craniotomy forceps, after having evacuated the contents of the cranium. 
This operation is, under such circumstances, attended with special dif- 
ficulties, which may render its performance a matter of difficulty or 
impossibility. Instead of being, as in most other cases, firmly held in 
position by the uterus, the foetus is apt to pass upwards on the slightest 
pressure towards the abdominal cavity ; and, if the rupture be a trans- 



XXVI.] VARIOUS METHODS OF TREATMENT. 439 

verse one, such pressure is apt to increase it; while, again, if a portion 
of the foetus has already passed into the peritoneal cavity, the remainder 
may thus be propelled in the same direction. It has been recom- 
mended, therefore, in order to obviate these difficulties, to use the per- 
forator so as to press the head back towards the hollow of the sacrum 
by directing the handles forwards as much as is possible in the direction 
of the subpubic angle. Success in an attempt such as this will be 
more probable if we avail ourselves of the aid of an assistant, whose 
duty it should be to maintain the child in the position which it occupies, 
by sustained and judicious pressure exercised through the abdominal 
walls. 

If we succeed in this way in effecting delivery of the child, we may 
then encounter another, and probably a more serious difficulty, in the 
extraction of the placenta. This organ, in a large proportion of cases, 
will be found to have escaped through the gap in the uterine parietes 
into the abdominal cavity, and, if contraction has subsequently taken 
place to any considerable extent, the aperture may thus be so reduced 
that great difficulty will be encountered in any attempt to draw it 
down. Too much caution cannot here be observed with the view of 
avoiding further laceration and extension of the wound. Were we to 
attempt to force the hand through the opening in order to seize the 
placenta, this would almost certainly occur. It is better, therefore, to 
use the cord as an extractor, and to pull the placenta towards the 
opening and then cautiously through it, and in this way complete the 
delivery. A prolapse or hernia of a portion of the intestine through 
the wound is by no means an unfrequent complication of such cases, 
and it is a matter of doubt in many instances whether we should or 
should not attempt to replace the protruding intestine. In so far as 
the risk of strangulation is concerned, this is a matter of trifling im- 
portance, for the usual situation and direction of the rupture, and the 
relation which it bears to the uterine fibres, render it a very unlikely 
matter that strangulation should occur ; and, apart from the chance of 
a recurrence of the prolapse, it may fairly be doubted whether the risk 
of displacing the clots and again disturbing the wound will not do 
more harm than good, — as recovery has taken place even when a con- 
siderable coil of intestine has passed through the wound and occupied 
the vagina. 

In a very considerable proportion of cases of rupture of the uterus, 
it is impossible to deliver by the natural channel, on account either of 
pelvic deformity, contraction of the os, or escape of the child into the 
abdominal cavity. In the first case, our course of procedure will depend 
upon the degree and extent of the deformity ; and, in the second, the 
rigidity may possibly be overcome by the use of chloroform, or even by 
incision of the tissues of the os, our object being, in every case in which 
the child remains in the uterine cavity, to deliver, if it be possible, per 
vias naturales. But, in the third case, when the child has escaped from 
the uterus, and lies among the intestines in the abdominal cavity, our 
treatment must be essentially different. So hopeless were such cases at 
one time generally regarded, that some of the most eminent accouch- 
eurs — Denman among others — recommended that we should not in any 



440 RUPTURE OF THE UTERUS. [CHAP. 

way interfere, but leave the case to nature, as it has happened that 
women, even under such desperate circumstances, have recovered, the 
child ultimately being discharged piecemeal by the ulcerative process, 
as in cases of extra-uterine pregnancy. In several cases in which rup- 
ture of the uterus and escape of the child into the peritoneal cavity had 
occurred, delivery has been effected and the woman saved by the opera- 
tion of turning, the hand being passed through the rupture, the feet of 
the child seized and brought down, and the delivery completed in the 
usual way. The fortunate result of these cases gave rise to a very 
general impression that this was the method of treatment most suitable 
for such cases ; but the gross results of the operation have turned out 
so unsatisfactory that a very general and growing belief now exists 
that, whatever may have been the result in rare and favorable instances, 
the chances of the woman are by this procedure rather diminished than 
increased. Dr. Barnes believes, and with some reason, that the cases 
alluded to were chiefly examples of rupture of the vagina, the rent of 
which is not contractile, and it is certain that it would scarcely be pos- 
sible to deliver in this way, in an ordinary case, without displacing the 
clots, increasing the rent, and thus exposing the woman anew to the 
danger of increased haemorrhage and redoubled shock. If it is to be 
performed at all, it seems to us to be applicable only to such cases as 
present a cervical rupture of considerable size, and in which the general 
condition of the woman is unusually favorable. 

The statistics of Dr. Trask, and the experience of later years, have 
very much modified the views previously entertained by competent 
authorities on the subject of gastrotomy in those cases of uterine rupture 
in which the child is in. the peritoneal cavity. The dangers of such a 
course are manifest. There is increased shock, and the special risk 
which attaches to all cases in which the cavity of the peritoneum is 
opened ; and, in addition to this, we may take into consideration the 
natural repugnance which is entertained by the patient's friends to such 
an operation, so long as another is in any way practicable. It must 
certainly be confessed that, in so far as it has been possible to institute 
a comparison between turning and gastrotomy in cases in which the 
child is outside of the uterus, the presumption is entirely in favor of 
the latter. The results of turning, and of removal through the rupture 
and the vulvo-uterine canal, are, according to Trask, as unfavorable to 
the mother as when we abandon the case absolutely to nature. But, 
in those in which the operation of gastrotomy has been preferred, the 
results have been much more favorable, about two-thirds of the cases 
collated by Trask having been saved. We must be very cautious, 
however, in admitting such figures as representing the true facts of the 
case, as we cannot but believe that many fatal cases are, for reasons 
which are sufficiently obvious, suppressed. This is the reason why 
here, as well as elsewhere in this work, comparative tabular statements 
are omitted as likely to lead to misapprehension and false hopes. The 
safety of the child is in all such cases a secondary matter ; but it may 
be admitted, as an element of the case for our consideration, that, where 
the operation of gastrotomy has been promptly performed, the child 
has occasionally been saved. On the whole evidence, then, we must 



XXVI.] LAPAROTOMY. 441 

pronounce in favor of gastrotomy when the child is in the peritoneal 
cavity, of turning when it has remained in the cavity of the uterus, 
and of the forceps or perforation where the head can be easily reached 
within the pelvis. 

The operation of gastrotomy, or Laparotomy, is simply the first stage 
of what will afterwards be more particularly described as the Caesarian 
Section. A longitudinal incision having been made in the middle line, 
below the umbilicus, with those precautions which the modern opera- 
tion of Ovariotomy has made familiar to us, the child is to be at once 
removed, along with the placenta and such clots as may be within 
reach. The wound should then be closed in the usual way, and a full 
opiate administered, while the patient is ordered to be kept in a state 
of perfect quiet, both of body and mind. Some difficulty may possibly 
arise, both before and after the operation, as to the use of stimulants. 
The condition of shock and general depression, and the state of the 
pulse may, on the one hand, indicate that we should not withhold them ; 
but, on the other, our apprehension of the dreaded, though inevitable 
peritonitis is such, that we shrink from any treatment which might 
tend to aggravate the inflammatory action, upon the degree and extent 
of which the life of the patient will depend, more, perhaps, than upon 
anything else. It is, in fact, impossible, in this particular, to lay down 
rules for our guidance; so that we must act, to the best of our judg- 
ment, as the exigencies and peculiarities of an individual case may seem 
to indicate ; but, it will probably be necessary, in most cases, to rally the 
patient in some degree from the shock which has attended the accident, 
before proceeding to perform the operation which we may have selected. 

In those cases in which rupture has occurred in the course of preg- 
nancy, the treatment will, in some measure, depend upon the stage of 
pregnancy. In so far as rupture in the early months is concerned, 
something must be allowed for the difficulty of diagnosis, as it would 
be difficult, in such a case, to know whether it was a rupture of the 
uterus, or of the cyst of an extra-uterine pregnancy. This distinction 
is not, however, one of any great practical importance, as the treatment 
in the two cases is probably identical, and there seems no reason to 
doubt that, in this case, the best chance would be to leave all to nature, 
in the hope that, by the ordinary process of ulceration, the foetus may 
ultimately be discharged. When the rupture takes place in the later 
months of pregnancy, the conditions are quite different, and the indica- 
tions of treatment are more those of rupture during labor. If we are 
certain that the foetus has escaped from the uterus, there must be no 
hesitation here as to the advisability of laparotomy. For, with an os 
firmly closed, it would be futile to attempt dilatation of it and the 
cervix as a preliminary to thrusting the hand through the uterus into 
the abdominal cavity, so that we cannot here even think of turning. 
Some have recommended, when the child is still within the uterus, a 
forced dilatation of the os, and even excision, to be followed by turn- 
ing ; but we very much question whether, even here, it would not be 
preferable to perform laparotomy, and extract the child from the womb 
by enlarging the laceration, should it be necessary. Under circumstances 
such as these, many w T ould probably prefer trusting to nature. 



442 DEFORMITIES OF THE PELVIS. [CHAP. 



CHAPTER XXVII. 

DEFORMITIES OF THE PELYIS. 

IMPORTANCE OF THE SUBJECT — CLASSIFICATION OF DEFORMITIES — CAUSES — DIS- 
EASES AFFECTING THE PELVIS: RACHITIS: MALACOSTEON : RICKETS AND 
MALACOSTEON CONTRASTED: NATURE OF THE BRIM DEFORMITY CHARACTER- 
ISTIC OF EACH— POSSIBILITY OF YIELDING IN A MALACOSTEON PELVIS — THE 
OBLIQUELY DISTORTED PELVIS — DEFORMITIES OF THE CAVITY: FLATTING OF 
THE SACRUM: FUNNEL-SHAPED PELVIS — DISTORTION OF THE OUTLET: AP- 
PROXIMATION OF THE TUBEROSITIES OF THEISCHIA: PROJECTION FORWARDS 
OF THE COCCYX: ANCHYLOSIS OF THE SACRO-COCCYGE AL ARTICUL VTION — MAS- 
CULINE TYPE OF PELVIS — INFANTILE TYPE — EFFECT OF MUSCULAR ACTION IN 
PRODUCING PELVIC DISTORTION — SPONDYLOLISTHESIS — PELVIC .EQUABI LITER- 
JUSTO-MAJOR, AND JUSTO-MINOR — OBSTRUCTION PROM EXOSTOSIS, OSTEOSAR- 
COMA, AND OTHER TUMORS; AND FROM FRACTURES OF THE PELVIS, AND 
MORBUS COXAR1US — SYMPTOMS— MEASUREMENTS OF THE PELVIS: PELVIME- 
TERS — EXAMINATION BY THE FINGERS — EFFECTS OF DISTORTION — DIFFERENCE 
BETWEEN "IMPACTION" AND "ARREST" — TREATMENT — PREVENTION — CIR- 
CUMSTANCES WHICH CALL FOR THE FORCEPS, TURNING, CRANIOTOMY — USE OF 
THE FORCEPS IN DEFORMED PELVIS — C.ESARIAN SECTION. 

Before passing to the more particular consideration of Operative 
Midwifery, it is proper that we should in the first instance turn our 
attention to the important subject of Pelvic Deformity; upon which 
condition a very large proportion of all midwifery operations depends. 
The first point which may be regarded as essential to the mastery of 
this important subject is, beyond all doubt, a correct appreciation of 
the normal standard, or, in other words, an accurate knowledge of the 
anatomy of the female pelvis. Upon this also, as we have already 
seen, hangs the whole theory of the mechanism of parturition ; but, so 
soon as deformity of any kind disturbs the relations which subsist be- 
tween the various pelvic diameters, it converts the harmonious whole 
of a normal pelvis into discordant elements, to which it is impossible 
to adapt such laws as under ordinary circumstances guide our action. 
If the art of obstetrics stopped short here, it would have little claim 
indeed to the dignity of a science. No point, however, within the area 
of our subject has attracted more of the attention of those to Avhose 
genius and industry we are under the deepest obligation ; and the 
light which their experience and investigation has thrown on it, 
enables us in these days to look upon the deviations from the normal 
standard to which we have alluded with more of confidence than ap- 
prehension. For the occurrence of difficulties more or less formidable, 
then, we must be prepared; and nothing will suffice for an intelligent 
and satisfactory appreciation of these, short of an intimate knowledge 



XXVII.] CAUSES. 443 

of the causes upon which pelvic deformities depend, and the practical 
contingencies which they involve. Many attempts have, from time to 
time, been made to classify and reduce these morbid conditions into 
genera and species, but they have been attended for the most part, in 
so far as practical results are concerned, with but indifferent success. 
Many of the best authorities, whom we shall in this matter attempt to 
follow, abandoning any such scheme, have therefore attached to the 
conventional phrase, " pelvic deformity," a signification somewhat be- 
yond what its etymology would seem to imply, so as to include, as we 
shall see, certain cases in which no deformity in the strict sense of the 
term exists, and yet in which the mechanical requirements of natural 
labor cannot possibly be assumed to exist. Many of the familiar terms 
arising from the systems of classification alluded to will be employed 
in the sequel, but only so far as may be necessary to meet the exigencies 
of formal description. 

The Causes of pelvic distortion are various; but by far the most 
important of these are the diseases known as Rachitis and Malacosteon, 
which, although closely allied in respect of the morbid conditions 
upon which they depend, are, nevertheless, to be carefully distinguished 
in regard to the difficulties which they engender, and the effects which 
they produce on the course of parturition otherwise natural. An elab- 
orate consideration of the pathological conditions, symptoms, and 
progress of these diseases is altogether foreign to a work such as this ; 
but there are certain points of similarity, and still more of contrast 
between the two, a knowledge of which is essential to a correct appre- 
ciation of the subject in all its bearings, and to which, therefore, it is 
necessary that we should at this place briefly advert. One of the most 
essential, and, in regard to our subject, one of the most important 
points of distinction between rachitis and malacosteon is, that while 
the former is a disease of childhood, the latter is a disease of adult life ; 
and it is only necessary to compare the form, and degree of inclination 
of the pelvis of an infant (see Fig. 17) with that of the adult, to see 
that the effect which must inevitably be produced in the two cases, by 
a yielding of the osseous structures, can only be attended with results, 
as regards the measurements and form of the pelvis, which of them- 
selves would suffice to establish a marked distinction. Such differences 
in form as results from the operation of this cause — to which we shall 
more particularly refer — are by no means the only features which fix 
our attention in this direction. 

Rachitis or Rickets is, as we have said, a disease of infancy and 
childhood, which very rarely comes on after the age of puberty. It is 
attended from the first by a marked cachexia, which the best authori- 
ties seem to regard as identical with that of scrofula ; but the first 
symptom which clearly points to the nature of the case, is the yielding 
of the bones, which soon gives rise to more or less of deformity in 
those parts of the skeleton which have most to do with the support of 
the body — namely, the spine, pelvis, and lower limbs. The chief 
morbid alteration upon which these phenomena depend is a diminution 
of the earthy constituents of the bones ; but the change goes much fur- 
ther than this, and involves corresponding alterations in the animal 



444 DEFORMITIES OF THE PELVIS. [CHAP. 

portion, and thinning of the dense or laminated texture, with a conse- 
quent predominance of the cancellated structure, and the formation of 
certain new and semi-solid products. Some bones suffer more than 
others, and even some parts of the same bone may be affected to a com- 
paratively greater extent. The amount of deformity which is thus 
produced will obviously depend, in a great measure, upon the extent 
to which the disease exists, and the continuance of the morbid condi- 
tions referred to ; but it is generally observed that the deformity is not 
confined to any particular part of the osseous framework, but affects it 
generally, the more conspicuous symptoms being spinal curvature and 
flexion of the bones of the leg. With the distortion in these regions 
we have here nothing particular to do ; but, as regards the pelvis, there 
is almost always more or less deformity caused by the weight of the 
trunk, which is thrown upon the bones of the pelvis from the spinal 
column through the sacrum. Another important point of special 
interest to us is that rachitis is usually accompanied with arrest of 
growth, which, although most marked in the lower limbs, and thus 
imparting dwarfishness to the frame, is also to be noticed in the pelvis, 
which is often, on this account, abnormal in respect of size as well as 
of distortion. We shall not further follow the symptoms and progress 
of such cases. It will suffice to observe that the general tendency is 
towards recovery, which is first indicated by an amendment of the gen- 
eral health, disappearance of the cachectic symptoms ; and, with more 
inclination for muscular action, a steady amelioration in the morbid 
condition of the bones, in which the phosphatic deficiency is gradually 
improved. Ultimately, the health and strength are permanently re- 
stored, but the period of restoration merely fixes the bones for life in 
the distorted position. Judicious treatment during the period of con- 
valescence no doubt often modifies the amount of ultimate deformity; 
but such treatment is usually directed to the spine and lower limbs, 
while the pelvis comes in for a much smaller share of attention. The 
accoucheur should always remember that the existence of spinal curva- 
ture is no evidence of antecedent rickets, a consideration which may 
be of importance, chiefly with reference to questions of prognosis. 

Malacosteon, or Osteomalacia, is much rarer than the preceding, and 
is essentially a disease of adult life. The process of ossification has, 
we may suppose, been satisfactorily accomplished ; and then come on, 
for the first time, the morbid conditions upon which the distortion 
depends. Although in this case, as in that of rickets, the most usual 
occurrence is a disproportion between the earthy and animal con- 
stituents of the bones, their whole structure suffers considerable altera- 
tion. It is more frequently observed in females than in males; while 
in rickets there docs not seem to be any preference for sex. The 
general symptoms which accompany malacosteon are, from an early 
period of the case, very grave. It usually runs a rapid course, mani- 
fests no tendency to repair, defies all attempts at treatment, and, sooner 
or later, has a fatal result. The disease may affect the whole skeleton, 
or may be limited to several bones, or to one; and it would appear 
that the pelvis at least rarely escapes. It would also seem to involve 
the entire texture of the affected bones more equably than rickets. 



XXVII.] MALACOSTEON. 445 

Softening: of the bones is the usual characteristic, but it may occasion- 
ally be attended with brittleness, to which the term Fragilitas Ossium 
has been applied. Mollities Ossium is not, therefore, to be accepted 
as absolutely synonymous with Malacosteon. 

In contrasting these two morbid conditions, the first point of im- 
portance to be noticed is that, in rickets, we are dealing, not with 
disease, but with the effects of disease, the pelvis being, in fact, often 
more dense in structure than if it never had occurred; while, in mala- 
costeon, we have actually existing and progressive disease. From this 
arises a practical point, which may be noticed here, although with no 
intention to exaggerate its importance. This is the possibility of some 
yielding of the bones of the diseased pelvis, so as to admit of parturi- 
tion, or of operative assistance which would otherwise be unavailable. 
A case of this kind is given by Osiander, who, being about to perform 
the Caesarian section in a malacosteon pelvis, made a final attempt 
by the hand — an attempt which, owing to such relaxation as is here 
described, actually succeeded. 

The condition and circumstances of the patient at the period of the 
occurrence are such as to exercise a very important influence on the 
nature of the distortion. Rickets, in most cases, comes on before the 
child has begun to walk, so that the most likely mechanism of distor- 
tion in these instances is a force acting through the spinal column, as 
we have already observed, upon a pelvis which, in comparison with 
the adult model, has a greater inclination and a conjugate diameter 
exceeding the transverse. In malacosteon, on the other hand, the 
patient may walk or stand during the process of softening, and the 

Fig. 13S. 




Rachitic pelvis. 

weight of the whole trunk is thus transmitted to the heads of the thigh- 
bones. This difference in the nature of the forces or mechanism of 
pelvic deformity is well shown in the characteristic features of rachitic 
and malacosteon pelves. In a typical case of the former variety there 
is, as shown in Fig. 138, a marked projection forwards of the sacrum 
by the operation of the cause above alluded to. This is by far the most 
frequent of all the varieties of deformity which have been described. 
It may (as shown in the figure) or may not be associated with flatten- 
ing of the anterior wall, and projection backwards of the symphysis 



446 



DEFORMITIES OF THE PELVIS. 



[chap. 






pubis, but the effect, in every case, is a more or less marked diminu- 
tion of the conjugate diameter of the brim. Different varieties of this 
distortion have been described as " masculine," " heart-shaped," and 
"figure of eight" deformities of the brim ; all of which are, as will be 



Fig. 139. 




Malacosteon pelvis. 

observed, mere modifications of the same condition, and all of which 
partake of the character of elliptical distortion. In malacosteon again, 
the general characteristic of the deformity is angular, and is due to 
antero-lateral displacement of the pelvic walls by pressure exercised 
upon the acetabula. This is indicated in a typical form by the rostrated 
variety shown in Fig. 139, where the conjugate diameter is increased 
at the expense of the transverse and oblique. 

Endless varieties and combinations of these two may occur, so that 
the distinction between a rickety and a malacosteon pelvis is only to be 



Fig. 140. 




Isabel Redman's case. 



accepted with the qualification that some cases partake of the charac- 
teristics of each. Thus, in the case of Isabel Redman, operated upon 



XXVII.] VARIETIES. 447 

by Dr. Hall, the conjugate and oblique diameters were both involved, 
constituting a very serious modification of distortion in this situation. 
These are, of course, mere illustrations of possible variations, which 
might be infinitely multiplied ; but it is to be remembered that a con- 
siderable number of cases have been met with in which an undoubtedly 
rickety pelvis presented all the more prominent characteristics of mala- 
costeon deformity. 

In so far as the true malacosteon pelvis is concerned, it has been well 
observed by Stanley that there is no diminution in the actual circum- 
ferential measurement of the brim, and that the bones are of their 
natural bulk and proportion, so that " if their various doublings were 
unfolded " the pelvis would be restored to its normal dimensions and 
form. In rickets, however, this does not usually apply, owing, as has 
already been observed, to the partial arrest of development which 
obtains during the course of the disease. 

In the majority of cases of pelvic deformity, there is a want of sym- 
metry, one side being affected to a greater extent than the other. This 
is due to a variety of causes, probably one of the most important being 
the alteration of the centre of gravity in consequence of spinal curvature. 
A very peculiar and extreme variety of this kind is that which was so 
fully described by Naegele in his memoir on the subject as the "pelvis 
oblique- ovata" or Obliquely Distorted Pelvis. In these very interest- 
ing cases, there is anchylosis of the sacro-iliac articulation on the affected 
side, which is flattened and its development arrested, as is shown in the 
figure. Half of the sacrum is imperfectly developed, and the oblique 
distortion is such that the whole of that bone is carried towards the 

Fig. 141. 




Obliquely distorted pelvis. 



affected side, while the sacro-iliac synchondrosis of the sound side is 
brought nearly opposite to the pubic symphysis.. 

Deformities of the cavity of the pelvis may either be associated with 
some of the above, or may exist independently. One of the best known 
of these, and which is by no means an uncommon cause of impaction 



448 



DEFORMITIES OF THE PELVIS. 



[CHAP. 



of the head within the cavity, is " flattening" of the sacrum as here 
shown. The normal recession of that bone being wanting, the conju- 
gate diameter of the cavity is proportionally curtailed, and the move- 
ment of rotation rendered im- 
FlG - 142 - possible. 

In other cases, the diameters 
of the pelvis are diminished from 
above downwards, so as to con- 
stitute what has been designated 
and described as the "funnel- 
shaped" pelvis. An example of 
this, from an original drawing of 
such a case, is shown in Fig. 143, 
in which the gradual approxi- 
mation of the ischial planes is 
greatly exaggerated, and the flat- 
tening of the sacrum contributes 
to the reduction of the conjugate 
diameter. Sometimes the curve 
of the sacrum is too great or too 
abrupt, as in the case represented 
in Fig. 144. This, however, might perhaps be supposed to come more 
within the category of distortion of the outlet, although it may, we 
apprehend, be fairly considered as contributing to both. 

Distortion of the outlet is necessarily involved in many of the varie- 




Flattening of the sacrum. 



Fig. 144. 




Funnel-shaped pelvis. 



Exaggerated sacral curvature. 



ties which have been described. The general effects produced in mala- 
costeon are, then, a narrowing of the transverse diameter, chiefly by 
approximation of the acetabula. This implies, as a reference to Fig. 
139 will more clearly show, a diminution of the corresponding diame- 
ters of the cavity and outlet, which brings the tuberosities of the ischia 
nearer to each other, and thus reduces the subpubic angle, so that the 



XXVII.] . VARIETIES. 449 

head must descend further in the direction of the perineum, before it 
can pass under the subpubic arch. And, in like manner, a diminution 
of the conjugate diameter at the outlet will materially impede the birth 
of the head. An abrupt curve of the sacrum, as shown in the accom- 
panying figure, will have this effect, and if there should be, as has been 
observed, anchylosis of the sacro-coccygeal articulation, the difficulties 
of the case will thereby be materially increased. When the deformity 
is confined to this part of the pelvis, it has been observed that approxi- 
mation of the ischial tuberosities is quite as frequent as conjugate con- 
traction. 1 

The masculine type of pelvis has already been mentioned in refer- 
ence to the deformities which exist at the brim. An extension of this 
to the cavity and outlet constitutes a very serious impediment to labor. 
In such cases, we may have the bones of the pelvis thicker, heavier, 
and more marked with muscular attachments, the cavity deeper — as is 
more particularly shown by the greater depth of the pubic symphysis, 
— and the subpubic angle rendered more acute by an approximation 
of the ischial tuberosities. Or, again, we may have an infantile type 
of pelvis, in which, from arrest of development, with or without rickets 
in other parts, the inclination of the brim is greater, and-the transverse 
diameter relatively less than is normal, while the whole pelvis is smaller 
than it should be. 

It is a fact familiar to every surgeon, that the action of the muscles 
plays a most important part in producing distortion of a rickety skele- 
ton ; but it would appear that this cause of pelvic deformity has not re- 
ceived anything like general attention at the hands of obstetric writers. 
The following observations on this point are borrowed from Dr. Mur- 
phy : " In the motions of the body, there are two sets of muscles con- 
nected with the pelvis to be considered, each having a distinct office to 
perform. One set, passing anteriorly and posteriorly, between the pelvis, 
and the thigh-bones, keeps the pelvis fixed to its position ; these, there- 
fore, would act very powerfully in distorting the softened bone to which 
they are attached, but would manifestly produce a much greater effect 
when the body is upright and the pelvis is made a centre of motion, 
as in the adult pelvis, than when the body is bent forwards, and moves 
less upon the pelvis, as in the child. Such we find to be the case : the 
lower portion of the sacrum and the coccyx is bent, nearly at a right 
angle, by the great gluteal and pyramidal muscles, and close up the 
outlet. Anteriorly, the effect is not so apparent in the adult pelvis, 
because it is counteracted by the acetabula and ischio-pubic rami being 
pressed in towards the centre; but still the edges of these rami are 
more everted, and the pubic arch itself, immediately beneath the sym- 
physis, is wider than it ought to be. The other set of muscles are 
those that maintain the body in its erect position ; posteriorly the 
dorsal ; and, anteriorly, the abdominal muscles. The tendency of the 
former is to draw the sacrum towards the spine, and thus to increase 
the projection of the promontory; the effect of the latter is to draw 

1 For an exhaustive account of the difference between malacosteon and rickety 
pelves, embodying the researches of Meyer r of Zurich, see an article by Dr. Mat- 
thews Duncan in the Edinburgh Medical Journal for April, 1856. 

29 



450 DEFORMITIES OF THE PELV1.S. [CHAP. 

the ilium more upright, and to render it more irregular. The action 
of these muscles will therefore explain the character of some of the 
distortions in the adult pelvis. In the infant pelvis, their influence is 
modified by the altered position of the body. In this case, the weight 
from above presses down upon the thigh-bones, and tends to separate 
them more from each other; the muscles, therefore, passing between 
them and the pelvis, will draw outwards that portion of the pelvis to 
which they are attached ; hence the ischio-pubic rami are more sepa- 
rated, and the tubera of the ischia more apart than natural ; but the 
distance of the thigh-bones being increased, the coccyx can still be 
drawn forwards by the muscles attached to it; consequently the outlet 
is much more open than it ought to be, and the abruptly-curved sacrum 
becomes the only impediment to the escape of the head." 

It will be understood that the varieties of pelvic deformity above 
described are far from embracing all that might be adduced, as our 
object has been to avoid complication by simplifying the subject as far 
as is consistent with a correct appreciation of the facts which may be 
supposed to bear upon practice. Some of the rarer deformities are 
figured in Moreau's atlas. There are still, however, one or two con- 
ditions which, although not strictly pelvic deformities, are very prop- 
erly considered along with them. Among these we may first mention 
deformity due to disease of the lower portion of the spinal column, 
in which curvature, or other displacement of the bones, may prove as 
effectual a bar to natural delivery as the more common varieties of de- 
formity at the brim. Of this nature is the affection which has been 
described under the name of Spondylolisthesis, when the last lumbar 
vertebra slips downwards and forwards, and directly encroaches on the 
conjugate of the brim. 

Nor can Ave omit to mention two other varieties of peculiarity in 
conformation, in each of which the shape of the pelvis, and relative 
measurements of its parts, are perfectly normal. The former of these, 
which has been termed the pelvis cequabiliter-justo-major, implies a 
pelvis which is symmetrically increased in all its diameters. Although 
such a conformation as this must necessarily act by facilitating labor, 
by the comparative ease with which it admits of the passage of the 
child, it is not to be regarded as a favorable condition. On the con- 
trary precipitate labor is always, and with good reason, looked upon 
with apprehension, as experience teaches us that, when moderate and 
normal resistance on the part of the pelvic walls is wanting, violent 
and rapid dilatation of the soft textures of the canal necessarily takes 
place, to the danger of their integrity at any part from the os uteri to 
the vulva ; and there are, in addition to this, other dangers, which will 
afterwards be more particularly described. The only advantage which 
may accrue from such a pelvis occurs, according to Churchill, in face 
presentations. To this we may perhaps add occipito-posterior posi- 
tions of the cranium, and, in the absence of all assistance, transverse 
presentations, as it would naturally favor spontaneous expulsion or 
evolution. The pelvis cequabiliter-justo-minor — the other variety re- 
ferred to — is the converse of this. We have here also a perfectly- 
shaped pelvis ; but all the diameters are less than is usual, so that a 



XXVII.] 



VARIETIES. 



451 



Fig. 145. 



special impediment must in every such case exist, in a degree propor- 
tionate to the extent of the symmetrical deformity. What makes this 
a condition more unfavorable than we might at first suppose, is the 
absence of any possible compensation in one direction for a deformity 
existing in another. We thus find that the moulding process is of 
much less avail here than where, for example, we have a moderate 
degree of conjugate contraction, with an ample measurement in the 
transverse, in which latter direction the head may, by compression, 
elongate itself, and thus, by changing its shape, pass the obstacle, after 
a certain amount of delay. 

We may here consider the effect which is produced by certain sur- 
gical diseases or accidents which may prove impediments, more or less 
insuperable, to normal parturition. These are in their nature various, 
and, in their extent, offer every variety from a slight encroachment 
upon a single diameter to complete blocking up of the true pelvis. 
Osteosarcoma and Exostosis are two 
of the most important of these affec- 
tions, and may constitute, if of any 
size, an impediment which renders 
delivery by the natural channel quite 
impossible. These tumors may take 
their origin from any part of the osse- 
ous tissue of the pelvis; but the situa- 
tion from which they most frequently 
spring is the upper third of the sa- 
crum, encroaching therefore upon the 
brim and cavity by spreading from 
this centre. Care must be taken, by 
examination through the vagina, and, 
if necessary, through the rectum, not 
to mistake these for abnormal con- 
traction of the brim, due to projection 
of the sacral promontory. This is 
an error which has been committed, 
and which would probably be in most cases avoided by external meas- 
urement of the pelvis ; and, if it should, in the course of such an 
examination, be discovered that the measurements in question were 
normal in extent, the presumption of exostosis would be increased. 
The absolute hopelessness, in the case of an exostosis of large size, of 
delivering by the vagina will appear by a reference to this familiar 
figure. Cancerous disease of the pelvic bones, resulting in the devel- 
opment of tumors of greater or less consistency, may be a serious me- 
chanical impediment to the course of labor, besides being a condition 
which involves the life of the mother. These may spring from any 
part of the pelvis, and will probably develop in the direction in which 
there is least resistance, so that, if they have their origin in the inner 
surface, they can scarcely fail seriously to reduce the diameters of the 
pelvis in the same manner as the benign tumors previously described. 

The projection from certain portions of the pelvis of osseous spiculse 
was made the subject of very painstaking investigation by Kilian, who 




Pelvic exostosis. 



452 DEFORMITIES OF THE PELVIS. [CHAP. 

found that a common situation of such spiculse is the margins of the 
various symphyses. It is not difficult to foresee the effect of such 
sharp thorn-like projections if they should chance to spring from the 
sacro-iliac synchondrosis, or from any other part of the brim of the 
pelvis ; and, indeed, in such cases, — which are fortunately very rare, — 
scarcely anything could be looked for but laceration of the uterus and 
possible rupture. It would appear to be a general belief, that bony 
growths from the pelvis are in some way associated with the gouty or 
rheumatic diathesis. Partial ossification of the sacro-sciatic ligaments 
has been sometimes observed, and, when this takes place, the peculiarity 
would, no doubt, be suggestive of the natural condition in some of the 
lower animals. From these, from the other ligamentous structures, 
and from the periosteum, tumors of the fibrous or fibro-sarcomatous 
variety may spring, which, when constituting an apparent deformity in 
the pelvis, have sometimes been successfully removed in the course of 
labor. Any attempt at the removal of the purely bony tumors is out 
of the question, but cases have occurred in which the texture of these 
tumors was so loose, and so entirely composed of weak cancellated 
structure, as to admit of being crushed or broken down, either by the 
foetal head or the manipulations of the accoucheur. 

Fractures of the pelvis are occasional causes of pelvic deformity, — 
either from the union of the fractured bones in a distorted position, or 
from the irregular development of callus in the direction of the pelvic 
cavity, the diameters being thereby reduced. Projections of this kind 
have been observed, in which the pelvic diameters involved were re- 
duced to the extent of one and even two inches. Very considerable 
deformity of the pelvis may also be the result of Morbus Coxarius, 
which has gone on to dislocation and anchylosis; or of fracture or dis- 
location of the head of the bone 1 , — the effect being due, in such cases, 
to the distorted condition of the limb acting, in all probability, on a 
pelvis which is morbidly softened, or at least in a constitution which 
is impaired. 

Symptoms. — These may, to a great extent, be inferred from what has 
been said in reference to the causes from which pelvic deformities are 
believed to arise. In marked cases, involving considerable deformity — 
such as may be due to Rachitis — the general distortion of the skeleton 
will point to the pelvis as a part of the solid framework of the body 
which can hardly be expected to have escaped. But an obvious rickety 
condition of the skeleton is no evidence whatever, either of the degree 
or of the nature of the deformity. It is necessary, therefore, in such 
instances, if we desire to gain an accurate knowledge of the nature of 
the case, to observe with great care the actual pelvic measurements, 
both externally and internally. The conjugate diameter is that which 
in most instances we are anxious to determine, and, in so far as this 
may be inferred from measurement in the living subject, it may be 
approximately ascertained by the use of Baudelocque's Calipers, which 
are here shown. By this, and making a deduction of about three 
inches for the soft parts, the measurement from the posterior sacral 
spines to the anterior surface of the pubic symphysis should be about 
seven inches. Such a method of examination as this is so manifestly 



XXVII.] 



PELVIMETRY. 



453 



open to the operation of disturbing causes, that little reliance can be 
placed on inferences which are drawn from it alone, so that various 
instruments have been devised, and a great amount of mechanical in- 
genuity has been expended, on the construction of an internal pelvime- 
ter. One of the earliest instruments of this kind was the pelvimeter 
of Coutouly, which closely resembles in its form the rule used by shoe- 



FlG. 146. 




Baudelocque's calipers, and Coutouly's pelvimeter. 



makers in measuring the length of the foot, and consists of two parts, 
one of which slides in a groove in the other. A limb projects from 
the extremity of each of these at right angles to it. The instrument is 
introduced beneath the arch of the pubis, and pushed onwards until 
the extremity touches the sacral promontory. It is held in this posi- 
tion, and the pubic portion is then slid forwards until it touches the 
posterior surface of the pubic symphysis. The distance of the sacrum 
from the pubic bones is indicated by the extent to which the anterior 
portion is thus drawn out, which is read off in inches marked on the 
stem. The total length of this instrument, which is also represented 
in Fig. 146, is about eleven inches. 



454 DEFORMITIES OF THE PELVIS. [CHAP. 

An immense number of pelvimeters have since then been invented. 
That which is shown in Fig. 147, as designed by Dr. Lumley Earle, is 
probably one of the best and simplest : it is to be introduced into the 
vagina with the shorter of the two limbs turned towards the pubis ; 
and, on the extremity reaching the level of the brim, as ascertained by 
the finger, along which it is carefully guided, the handles are pressed 
together, and their divergence read off on the scale which is between 
them. The objection to all such internal instruments is, that they are 
difficult of application so as to insure accurate results, and besides not 
altogether safe unless used with great caution. Coutouly's is, for 
reasons which are quite obvious, inapplicable to cases in which the 
woman is in labor, and, indeed, to cases of pregnancy, so that in the 
very instances in which we are most anxious for exact information, it 
is practically valueless. Dr. Earle's is, no doubt, from this point of 
view, to be preferred. But even when, in the absence of pregnancy, 
we may wish to ascertain the condition of the pelvis, it is by no means 
an easy matter to use either the one or the other. 

All such contrivances, indeed, as have hitherto been invented are 
open to the objections which have just been stated. Many of the best 
authorities have, on this account, absolutely discarded them, and prefer 
the simpler method of investigation by the finger. The various methods 
by means of which we may thus gain information have been admirably 
described and illustrated by Dr. Ramsbotham. "Three methods," he 
says, " are practiced : one is, by the introduction of the first finger of 
the right hand within the vagina, so that the point should be carried 
up to, and touch the sacral promontory, while the root of the finger is 
applied exactly under the symphysis pubis, at the upper part of the 
arch. It must be evident that this mode of inquiry will be of no avail 
unless the pelvis be greatly distorted — considerably under three inches, 
indeed, in the conjugate diameter. For the ordinary length of the 
index finger along its inner edge is less than three inches ; and as the 
oblique line from the promontory to the apex of the pubic arch exceeds 
the direct line across, so if there be more than the space just mentioned, 
the finger would not be able to reach the projection, and we should 
consequently be in utter ignorance what amount of room existed. If 
the pelvis be very small, the sacral promontory can be felt with ease; 
but, even in that case, the dimensions of the direct conjugate diameter 
is not afforded, but the length of the oblique line is given ; and it is 
not always possible to calculate the difference between these two lines 
accurately." 

" Another mode which has been recommended is the introduction of 
the whole left hand within the pelvis, with the outside or point of the 
little finger touching the inner surface of the symphysis pubis, and the 
first finger placed against the promontory of the sacrum. As every 
man is aware what his hand measures across, it is supposed he will be 
able to ascertain the transverse (conjugate?) diameter of the pelvis. 
Thus, presuming the hand to be two inches and three-quarters wide, 
which is the common average about the centre of the fingers, if, when 
placed edgeways, it just fits the brim, the examiner will know that 
the space is within three inches. Again, if he can only introduce three 



XXVII.] 



MANUAL PELVIMETRY. 



455 



fingers instead of four, he will know that the pelvis does not measure 
two inches, and probably not so much ; and, if he can only pass up 
two fingers, closed together, he will be assured that there is not more 
than an inch and three-eighths. But, on the contrary, if, in introducing 
the whole hand, he be compelled to spread his fingers widely before he 
can touch the sacral promontory, he will then be certain that the space 
is more than three inches, probably four, or near it. But it is not always 
easy to follow this mode of inquiry, because the child's head is generally 
protruded somewhat into the pelvis, even when the brim is contracted ; 
and we could not carry the hand up in this manner, and make the 
accurate examination which we require to do, unless the brim as well 
as the cavity were perfectly free and unoccupied. It might, perhaps, 
be employed with advantage, provided the deformity was excessive." 



Fig. 147. 



Fig. 148. 




Lumley Earle's pelvimeter. 



Manual pelvimetry. (Kamsbotbam.) 



" The third method I consider the best, and is the one I myself 
adopt. Two fingers of the left hand are to be carried within the vagina ; 
the extremity of the first finger is to be placed exactly behind the sym- 
physis pubis, and the tip of the second against the sacral promontory. 
(See Fig. 148.) By stretching the fingers in this way, we shall have 



456 DEFORMITIES OF THE PELVIS. [CHAP. 

little difficulty in reaching the promontory of the sacrum, even when 
the pelvis is of ordinary dimensions; and by withdrawing them in the 
same position, we may measure off the distance between their extremi- 
ties on the first finger of the right hand, or on a scale of inches, or with 
the limbs of a pair of compasses; and, consequently, we arrive at an 
accurate knowledge of the great dimensions of the pelvic brim. The 
laxity of the vagina, and other soft structures, which almost invariably 
attends the process of labor, will permit the fingers to be withdrawn 
while extended ; and if the examiner uses sufficient care, they may be 
kept perfectly steady until the space which they embrace be ascertained. 
This mode Of proceeding possesses a great advantage over the other two, 
inasmuch as we are able equally well to make our examination, whether 
the head be occupying a part of the pelvic cavity, or whether it be still 
detained quite above the brim ; for, even if it be engaged in the vagina, 
one finger may be passed anterior to, and the other behind it, with 
comparative ease." 

It is only, however, after considerable experience that such arbitrary 
methods of examination are of much value in diagnosis. Very marked 
deformity is usually recognized easily enough, but the more important 
question of the degree or amount of distortion is not so readily solved, 
and will always require most careful and exact observation. It is upon 
the latter, indeed, that the most important practical considerations 
hinge ; and upon the result of such an investigation, be it right or 
wrong, will depend whether, in a given case, we determine in favor of 
operation by the forceps, turning, craniotomy, or the Caesarian section. 
The actual measurements which relate to these operations will be more 
particularly considered in the chapters which follow. 

The effects, direct and indirect, of pelvic deformity, are often very 
serious, and are usually to be observed, as might be anticipated, in 
neglected or mismanaged cases. A common result of long-continued 
pressure upon the tissues of the os and cervix is sloughing of these 
parts, attended with irritative fever, and general symptoms even more 
severe than this. The destruction of tissue which is involved in this 
process may result in fistulous openings into the bladder or rectum, 
requiring subsequent operative procedure for their cure. The deformi- 
ties are, as is universally admitted, frequent causes of rupture of the 
uterus, sometimes from actual bursting, violence of the pains, and, in 
other cases, by pressure of the walls of the uterus against some part of 
the brim of the pelvis. The great amount of pressure which is ex- 
ercised in these cases is occasionally shown in a significant manner by 
the moulding and alteration in shape of the child's head. This some- 
times presents an indentation of the parietal bone from the pressure of 
a projecting sacral promontory; and, under the influence of the same 
cause, even fracture of the parietal bone has taken place. Another 
marked effect, produced by the arrest of the child's head or other pre- 
senting part, is the formation of a caput succedaneum of very unusual 
size, in the observation of which a serious error may arise. The for- 
mation of this swelling is a process of gradual development in the 
direction of the vagina, and not of sudden growth : it may, therefore, 
happen, that an inexperienced person, who feels that the actual surface 



XXVII.] TREATMENT. 457 

of the scalp approaches nearer and nearer to the finger, may take this 
as evidence of a gradual advance of the head, the passage of which may 
nevertheless be absolutely barred. If, in consequence of this or any 
similar error in judgment, the case is left too long to nature, the powers 
of the woman progressively decline, and she soon reaches a condition 
in which we act at a great disadvantage, and even with much appre- 
hension as to the ultimate result. 

In cases of extreme deformity, the head does not even engage in the 
brim, so that the effect of the ordinary expulsive efforts is simply to 
pinch or compress the lower segment of the uterus against the pelvic 
walls, while the os is being slowly dilated by the bag of waters. When 
the deformity is confined to the brim, and the promontory is not within 
reach of the finger, the nature of such a case is probably sometimes 
overlooked at first, as the examiner may conclude, from a simple ex- 
ploration of the vagina by one finger, that everything is quite normal 
and that the presenting part will descend presently. In other instances, 
the obstruction being less in degree, the vault of the cranium passes 
the plane of the brim, and the head is only arrested when its principal 
diameters come to be involved ; and, in a third class of cases, the 
obstacle being in the cavity or even at the outlet, labor goes on quite 
naturally until the head reaches the particular plane at which the 
obstruction exists. 

There is one point, in reference to these cases, in which it is of much 
importance that we should ascertain the relative condition of the parts 
involved : this is best expressed by drawing a careful distinction between 
the terms "impaction" and "arrest," which are sometimes used some- 
what loosely, as if the expressions were synonymous. By impaction, 
we should imply only such a condition of the head as consists in its 
being actually jammed in the pelvis. In such a case, not only does 
the head make no advance with the pains, but it does not recede during 
the interval, so that it is immovable in both directions. In a case in 
which the head is only arrested, however, there may be an equal impos- 
sibility as regards the advance of the head ; but its recession during the 
interval between the pains shows that the period of impaction has not 
yet been reached — a point which may be of very considerable importance 
in regard to the probable success or failure of a given operation. 

Treatment — -The management of cases of pelvic deformity will be 
treated of in detail when, in the subsequent chapters, the various opera- 
tions are considered, the necessity for which arises in a great measure 
from this particular cause. The accoucheur is occasionally consulted 
in reference to such cases, at a time when the dangers of pelvic distor- 
tion may be averted or modified. If it be a question as to marriage, 
it may be a very difficult as well as a delicate matter to decide, in a 
rachitic patient, between celibacy and the possible dangers of pregnancy ; 
but, if the case should be put before us, we must simply advise accord- 
ing to the facts revealed in the course of a thorough examination, when, 
if there should be evidence of such distortion as would probably call 
for the operation of craniotomy, it will be proper to withold our sanction 
to a marriage under such circumstances. Another possible case, in 
which prevention rather than treatment may require consideration, is 



458 DEFOKMITIES OF THE PELVIS. [CHAP. 

when the woman is pregnant, and the evidence of extreme distortion is 
clear ; or when, in previous pregnancies, labor has only been terminated 
by the sacrifice of the child. In both of these instances, the question 
which arises is that of the induction of premature labor, by which alone, 
it may be, the safety of the mother can be insured. It is generally, 
however, in the course of labor at the full time that the nature of the 
case is disclosed, and prompt and decisive treatment called for. 

Having endeavored to ascertain, approximately at least, the amount 
of distortion, we must, in the first instance, decide whether, and if so, 
to what extent, we should give nature a chance. In the minor degrees 
of pelvic deformity, it is always proper to do so, if the strength of the 
patient be not exhausted, and the uterine effort not unduly violent. 
When the cranium is of moderate size, it frequently occurs that, even 
in unpromising circumstances, the head becomes so moulded as to pass 
with perfect safety both to mother and child, although probably after 
a tedious labor. If the head is not actually impacted, we may have 
the choice of three operations, — the forceps, turning, or craniotomy; 
but when impaction has taken place, it is impossible to pass the hand, 
and, therefore, turning is struck out of our calculations altogether. In 
every case in which the head is in the cavity or at the outlet, the forceps 
should be preferred, unless, indeed, there is clear evidence that the 
head cannot pass without a reduction of its bulk, when any attempt of 
this kind would be worse than useless. If, however, the head should 
be at the brim, the use of the long forceps involves other and more 
serious considerations, and is, indeed, generally regarded as an opera- 
tion so dangerous that not a few of the most distinguished of modern 
obstetricians have expressed a decided preference for turning over the 
forceps, and even, under certain circumstances, for turning as compared 
with craniotomy when the head is in this particular situation. The 
general rules which are laid down for our guidance in the application 
of the forceps in ordinary cases are, to a limited extent only, of avail 
here. The altered conditions of a deformed pelvis, differing more or 
less in every case, put such rules as serve for the normal pelvis com- 
pletely out of the question. Instead, for example, of applying the 
blades to the sides of the head, it is often necessary to apply them to 
the forehead and occiput, and, in general terms, it may be said that our 
duty is to apply them in the direction where we have most room, and 
where we can get the firmest grip of the cranium. Thus, if the head 
is arrested at the upper portion of the cavity, in consequence of projec- 
tion of the sacral promontory, the sides of the head will probably be 
strongly compressed in the reduced conjugate diameter. The insertion 
of the blades of the forceps in such a direction would, therefore, be 
practically a matter of great difficulty, if not impossibility ; so that the 
operator should at once, and without hesitation, apply the blades to the 
long diameter of the head in the'transverse of the brim. 

If the head is at the brim, and the distortion not excessive, it will 
be quite proper, as we conceive, to make a gentle attempt by the long 
double-curved forceps, which should be of considerable strength in 
construction, in order to gain an efficient hold, and to prevent slipping. 
The operator, bearing in mind the immense power of such an instru- 



XXVII.] TREATMENT. 459 

merit, will be excessively cautious in the amount of force which he em- 
ploys, and will only persist if he observes some indication of yielding. 

Putting, for the moment, out of the question what have been called 
long-forceps cases, there are few points, of undoubted practical impor- 
tance, in reference to which greater difference of opinion obtains, than 
with regard to the proportion of cases in which we are justified in ap- 
plying the forceps in the minor degrees of pelvic disproportion. When 
we find one practitioner of experience using it only once in a hundred or 
even in several hundred cases, and another, of equal, experience, in 
every eight or ninth case, it is by no means easy to decide who is in 
the right. For our part, we entertain a very confident belief that the 
practitioner who uses the forceps in less than five per cent, of all his 
cases exposes many of his patients to needless pain and increased risk, 
and is pretty sure, in his practice, to lose more children in labor than 
he ought. 

When the decision lies between turning and craniotomy, we must 
first be sure that, if we succeed in turning, the head can be got through 
the contraction ; for it sometimes happens that, after turning, delivery 
can only be accomplished by perforating behind the ear. It must, 
therefore, be obvious, that it would be better to perforate, and deliver 
at once, than to turn and then perforate, thereby subjecting the woman 
to a twofold danger. We must also be able to displace the presenting 
part without employing much force, so as to introduce the hand into 
the uterus ; and it is certain that, when this cannot be done without 
violence, it is better at once to desist. One of the most important 
bearings of this interesting subject is whether the child is alive or not, 
which may be ascertained by the stethoscope in the usual way. If it 
is so, the possibility of saving the child, — which has sometimes been 
done when the general condition seemed little to encourage the hope 
of such a favorable result, — is the strongest possible inducement we 
can have for choosing turning, giving the child the chance at least, 
small though it may be, of which craniotomy necessarily deprives it. 

Among the minor arguments which have been used in support of 
this procedure, may be mentioned the repugnance with which one 
naturally regards any operation which involves the mutilation of the 
child, and the use of instruments instead of the hand. And, again, as 
has very clearly been pointed out by Simpson, there is an undoubted 
advantage in the manner in which "the transit of the cone-shaped head 
of the child, through a somewhat narrow brim, is facilitated by the 
narrow end of the cone (or bimastoid diameter of the head) being made 
to enter and engage first in the contracted brim ; and the hold which 
we obtain of the extracted body of the child enables us to employ so 
much extractive force upon the engaged foetal head, as to make the 
elastic sides of the upper and broader portion of the cone (or biparietal 
diameter of the cranium) to become compressed, and if necessary in- 
dented, between the sides of the contracted brim." Besides, the opera- 
tion of turning, when it can be effected, even after some time, and with 
some difficulty, is, there is good reason to believe, more safe to the life 
of the mother than that of craniotomy ; so that, even when the child 
is dead, it is often to be preferred. But, when the child is dead, and 



460 THE FORCEPS. [CHAP. 

turning is unusually difficult, or impracticable, we must consent to 
waive the objections which have just been stated, and substitute craniot- 
omy without delay. This, then, is a question of great practical im- 
portance, and is still receiving, at the hands of the ablest obstetricians, 
the attention which it merits ; but the limits of this work preclude a 
more extended analysis of the facts which bear upon the subject. 

When the pelvic distortion is excessive, and more than one of the 
diameters is encroached upon to a great extent, as has frequently been 
observed in malacosteon pelves, it may be quite impossible to deliver 
the woman by means of any of the operations which we have mentioned. 
We ma} r , in such instances, have no resource but the desperate one of 
the Caesarian section. What specific conditions may be held to justify 
the performance of that particular operation, we shall afterwards at- 
tempt to show; but, in regard to it, as well as the other methods of 
operative procedure, it is well-nigh impossible to lay down hard-and- 
fast rules, which may seem, in any strict sense, reliable, as for our guid- 
ance. An attempt will, however, be made to state the measurements, 
and other conditions, which are held, by the most competent authori- 
ties, to be warrant for the preference of one operation over another. 

The above remarks have had reference to cranial presentations only ; 
but it is, of course, to be kept in view that any other presentation may 
occur, and thus develop new and special considerations. An intelligent 
combination of the general principles upon which such presentations 
are to be managed, and an adaptation of these to the special circum- 
stances of the case, will enable the well-informed practitioner to con- 
duct such cases also in a skilful and creditable manner. 



CHAPTER XXVIII. 

THE FORCEPS. 

HISTORY OF THE FORCEPS — CHAMBERLEN'S FORCEPS — INVENTION OF THE PELVIC 
CURVE — THE SHORT FORCEPS : CASES TO WHICH IT IS APPLICABLE — REASONS 
FOR PREFERRING THE STRAIGHT FORCEPS IN MOST CASES — CIRCUMSTANCES IN 
WHICH THE FORCEPS IS REQUIRED — APPLICATION OF THE FORCEPS : CONDITIONS 
ESSENTIAL TO SAFETY : DEGREE OF DILATATION OF THE OS : IS IT NECESSARY 
TO FEEL AN EAR? MEMBRANES TO BE RUPTURED : BLADES TO BE APPLIED TO 
THE SIDES OF THE HEAD: FORCEPS TO BE APPLIED IN THE OPPOSITE OBLIQUE 
DIAMETER TO THAT OCCUPIED BY THE HEAD OF THE CHILD — THE OPERATION: 
INTRODUCTION OF THE " LOWER" AND " UPPER" BLADES IN THE FIRST CRA- 
NIAL POSITION — APPLICATION TO THE OTHER CRANIAL POSITIONS. 

The subject of operative Midwifery, naturally commences by a con- 
sideration of the great Prime Mover of Obstetrics, as the Forceps has 
not inaptly been termed. It is scarcely possible to exaggerate the im- 



XXVIII.] EARLY INSTRUMENTS. 461 

portance of this instrument, which is simple in construction, easy of 
application, and marvellous in power; and, besides, the greater fre- 
quency with which we avail ourselves of its aid, as compared with 
other methods of instrumental and operative assistance, fully entitles 
it, and its application in practice, to the prominent position in which 
the subject is invariably placed. 

No doubt can be entertained that the ancients discovered, and were 
in the habit of using, an instrument which, in the principle of its con- 
struction, is identical with the modern forceps. The period at which 
the discovery was actually made will probably never be known. It 
does not appear that the knowledge of the subject was general, even 
among the most civilized communities, but it is certain that it was 
well known to the early Arabian physicians. We thus find it men- 
tioned by Avicenna, and more particularly described by Albucasis, 
who lived about the eleventh or twelfth century. The latter describes 
two kinds of forceps, the misdach and the almisdach, both being ac- 
cording to the Latin version circular and full of teeth. It is worthy 
of note that, in the Arab original, which Smellie seems to have seen in 
the Bodleian library at Oxford, the misdach is described as straight, 
and the almisdach as curved. This important discovery was, however, 
completely lost sight of in the gloom of the dark ages, nor was it till 
the middle of the seventeenth century that it was rediscovered and, 
after a long interval of secrecy, introduced into practice. 

The discovery w T as made, as Dr. Churchill has clearly made out, by 
Dr. Paul Chamberlen prior to 1647, and was communicated by him to 
his sons, who were also members of the profession. The secret seems,, 
however, to have been greedily guarded by the Chamberlen family 
for their own profit; and Dr. Hugh Chamberlen, who translated into 
English Mauriceau's work on Midwifery, alludes to it in the preface 
to that work as late as 1716. Referring to the use of the crotchet, he 
says, " but I can neither approve of that practice, nor of those delays, 
beyond twenty-four hours, because my father, brothers, and myself 
(though none else in Europe as I know) have, by God's blessing and 
our industry, attained to, and long practiced a way to deliver women 
in this case without any prejudice to them or their infants; though all 
others (being obliged, for want of such an expedient, to use the common 
way) do and must endanger, if not destroy, one or both, with hooks.' 7 
As a sort of apology for keeping it secret, he adds, " there being my 
father and two brothers living that practice this art, I cannot esteem 
it my own to dispose of nor publish it without injury to them." 

The political troubles of his time obliged Dr. Hugh Chamberlen, on 
two occasions at least, to fly the country and take refuge on the Con- 
tinent, where he made various attempts to dispose of his invention. 
His offer to sell it to the French Government was refused, chiefly 
on account of the failure which had attended his efforts to deliver a 
woman upon whom Mauriceau had resolved to perform the Caesarian 
operation, and which was therefore a case, as we may assume, quite 
unsuitable for the operation by the forceps. He was more successful, 
however, in Holland, where he managed to. dispose of his secret to 



462 



THE FORCEPS. 



[CHAP. 



Fig. in 




Sketch of Chamberlen's for- 
ceps. (Rigby.) 



several practitioners, of whom the eminent Ruysch, the anatomist, 
was one. From the Netherlands to Germany, where it was used by 
Solingen, and ultimately to France, the secret 
slowly spread, until it was a secret no longer^ 
and was recognized in all its importance by the 
most accomplished accoucheurs of the day. 
Long before the operation had thus made its 
way into notice on the Continent, the secret in 
this country had undoubtedly oozed out in 
some quarter; and, ultimately, the midwifery 
forceps was described and figured by Chapman, 
in his well-known work, as the instrument used 
by the Chamberlens. A very interesting dis- 
covery was made in the old manor-house of a 
small estate near Maiden, in Essex, which 
had been purchased by Dr. Peter Chamberlen 
towards the end of the seventeenth century, 
and which had remained in the family till 
about 1715. In an old chest in one of the 
rooms of this house, there was discovered, in 1818, a collection of ob- 
stetric instruments, along with old coins, trinkets, and the like. Mr. 
Cansardine, into whose possession these relics had fallen, gave an inter- 
esting description of them in the Medico- Chirurgical Transactions , Vol. 
IX. There were several pairs of forceps, showing apparently the 
various stages of advancement through which the invention passed in 
Chamberlen's hands before he reached what he believed to be perfec- 
tion. Fig. 141) shows one of the most perfect of these, in which the 
blades are fenestrated, and are so constructed as, when separately ap- 
plied, to be articulated together at the shank by means of a pivot. 
This instrument, as perfected by Giffard and Chapman, is essentially 
the same as the forceps most frequently used at the present day, except 
in so far as the lock is concerned. 

Up to this time the handles of all the instruments were, as in the 
French forceps to the present day, of iron, and the lock was either a 
pivot, with or without a screw; a sort of mortice lock, like the blades 
of a pair of scissors; or the blades were clumsily tied together, after 
their adjustment, by means of a tape or cord. We are certainly indebted 
to Smellie for the simple contrivance which is known as the English 
lock, and also for the adaptation of wooden handles, which give a much 
better hold and purchase. The principle upon which all forceps were 
essentially constructed was to adjust the curve of the blades with refer- 
ence only to the spheroidal shape of the child's head, so as to make sure 
of securing an efficient hold without risk to the child. The difficulty 
in the application of such an instrument as this, when the head was at 
the brim or at the upper part of the cavity, led to another important 
modification of the forceps, the credit of which is divided between 
Levret and Smellie. It is most likely, however, that the French ob- 
stetrician was the real inventor; but it is to be regretted, for the sake 
of his reputation, that he made a secrect of it, as the Chamberlens, to 
their lasting discredit, had done before. 



XXVIII.] SHORT FORCEPS. 463 

The novelty in question consisted in the adaptation of a second curve 
in the blades, with reference, in this instance, to the curved axis of the 
pelvic canal. This is called the "pelvic curve/' and is the invariable 
form of the French forceps of the present day; while, in this country, 
the straight forceps lias been entirely abandoned by some of the most 
eminent of our obstetrical authorities. This variety was originally con- 
structed in order to overcome difficulties at the brim and high in the 
cavity, and it is, therefore, to these that it is chiefly applicable ; although, 
as has been said, many prefer this form in all cases, and allege that it 
is easier in application, and safer both to mother and child. We do 
not intend to enter at any length upon the controversy of single versus 
double-curved forceps; but it is proper to mention that Dr. Barnes, i\w 
latest English authority on the subject of operative midwifery, pro- 
nounces, in yevy emphatic terms, in favor of the latter, in all cases, 
whether at the brim, in the cavity, or at the outlet. For our part, 
although we cannot subscribe to this doctrine, Ave are quite confident 
as (o (he superiority of the pelvic curve in all cases where the head is 
at the brim or high in the cavity. 

Long and Short Forceps are described by all English writers as dis- 
tinct varieties of the instrument, and are sold by the makers under these 
names. The Short Forceps, as usually constructed, is an instrument 
about eleven inches in length, the measurement from the lock to the 
tip of the blades being a little over seven inches. Each blade is fenes- 
trated, the aperture being destined, on each side, to receive the parietal 
protuberances. The blades arc curved, so as to measure between their 
widest part about three inches, and from tip to tip, when closed, not more 
than an inch. This instrument when made without a pelvic curve, is 
known as Smellie's forceps, and is still used in this country more fre- 
quently than any other Conn. When it is applied to the child's head 
within the pelvis, the handles should be about an inch apart. It is 
scarcely necessary to observe, what is equally applicable to any variety 
of forceps, that, the blades should be made of steel of the finest temper; 
otherwise, they are constantly apt to slip over (he head by yielding of 
the metal. The edges are highly polished, and bevelled off in every 
direction with great care, so as to avoid the possibility of injuring the 
scalp of the child or the soil parts of the mother. Covering the blades 
with leather was once practiced, but this has now properly fallen into 
disuse, as rendering the instrument more difficult of introduction, and 
more likely to convey infection. Nor is the practice of covering them 
with a, composition of gutta-percha to be commended; and, when 
properly made, the clean, smooth metal is, on all accounts, to be pre- 
ferred. The short forceps is suitable for the extraction of the head 
from the outlet and lower part of the pelvis; but if the head is higher 
in the cavity, this instrument, although it may still be used with diffi- 
culty, is not to be recommended when one more efficient is at hand. 
Its use should be limited to those instances in which it is possible, after 
adjusting the blades, to close them while the lock is still quite clear of 
the external parts, li' the lock passes within the; vulva, there is con- 
siderable danger, — especially when the woman is under the influence 



464 THE FORCEPS. • [CHAP. 

of chloroform, and is thus unable to give any evidence of particular 
suffering — of pinching in some portion of the soft parts, and inflicting 
serious laceration. 

To obviate this risk, and at the same time to render the forceps 
capable of more extended application, we have always advocated the 
employment, in ordinary practice, of an instrument which is both longer 
and stronger than the ordinary short forceps. Such an instrument as 
this, which fulfils equally well all the purposes of the short forceps, is 
also applicable to cases in which the head occupies the middle third of 
the cavity, or even a little higher. In these latter cases, the lock is 
still external, and the power of the instrument is considerably increased. 
The handles are stronger, and the blades thicker, than in the ordinary 
short instrument; for it is a fundamental rule, in the construction of 
the midwifery forceps, that, for obvious mechanical reasons, w T e must 
increase the strength in proportion to the length of the blades. And, 
in doing so, it is also proper so to construct the handles as to give the 
operator sufficient power; as no greater error can be committed than to 
sacrifice power to elegance, or to a dislike to give the instrument a 
formidable appearance. The following remarks by Dr. Barnes are so 
apposite to this, that we quote them here. " It has been sought," he 
says, " to make an instrument safe by making it weak. There can be 
no greater fallacy. In the first place, a weak instrument is, by the 
mere fact of its weakness, restricted to a very limited class of cases. 
In the second place, if the instrument is weak it calls for more muscular 
force on the part of the operator. Now, it is sometimes necessary to 
keep up a considerable degree of force for some time, and not seldom 
in a constrained position. Fatigue follows; the operator's muscles 
become unsteady; the hand loses, its delicacy of diagnostic touch ; and 
that exactly-balanced control over its movements which it is all-impor- 
tant to preserve. Under these circumstances, he is apt to come to a 
premature conclusion, that he has used all the force that is justifiable; 
that the case is not fitted for the forceps, and takes up the horrid per- 
forator; or he runs the risk of doing that mischief to avoid which his 
forceps was made weak. The faculty of accurate gradation of power 
depends upon having a reserve of power. Violence is the result of 
struggling feebleness, not of conscious power. Moderation must ema- 
nate from the will of the operator; it must not be looked for in the 
imperfection of his instruments. The true use of a two-handed forceps 
is to enable one hand to assist, to relieve, to steady the other. By 
alternate action the hands get rest, the muscles preserve their tone, and 
the accurate sense of resistance which tells him the minimum degree of 
force that is necessary, and warns him when to desist." 

It is, perhaps, natural that an operator should prefer that form of 
forceps to the use of which he has been trained, and upon which he 
knows, by experience, that he can thoroughly depend in times of danger 
or difficulty. In confessing, however, a personal predilection for the 
straight forceps, it is proper to observe that many of the most expe- 
rienced and distinguished practitioners, both in this country and abroad, 
express a decided preference for the pelvic curve. No English writer 



XXVIII.] 



STRAIGHT FORCEPS. 



465 



Fig. 150. 



has so emphatically pronounced against the straight variety as Dr. 
Barnes, in his recent work. Personal experience, which is corroborated 
by that of many able and experienced accoucheurs, prevents us from 
perceiving the strength of his arguments, or the justice of his conclu- 
sions ; and we object more particularly to the assertion that the straight 
forceps is especially dangerous to the child. It may well be that the 
pelvic curve in the hands of those skilled in its use is equally efficient. 
That it is so, cannot, indeed, be doubted, and it is possible that, when 
once adjusted, the danger of slipping is less when used by the inexpe- 
rienced, but we conceive that such problematical advantages are more 
than counterbalanced by the following : First, the blades are more 
easily introduced, with reference to the position of the child's head, if 
the operator has but one curve to think of; 
second, the two blades being the same, no 
mistake can possibly be made between the 
upper and lower, or anterior and posterior 
blade ; and third, that if it should be found 
necessary to alter the position of the head 
by rotation, this can only be effected by the 
straight instrument. 

The forceps, the use of which we recom- 
mend to young practitioners, who generally 
possess but one, is an instrument of a size 
intermediate between the ordinary short 
forceps and what will presently be described 
as the long forceps. It is, as already men- 
tioned, applicable for all the purposes of 
the short forceps, but by means of it we are 
able to operate quite as easily when the 
great diameters of the head are on a level 
with the middle plane of the pelvis. It is 
fourteen inches in length, the blades to the 
lock being nine, and the handles five inches. 
The fenestras are four and a half inches in 
length, and something less than an inch 
and a quarter in the widest part. The dis- 
tance between the blades in the widest part 
of the curve is three inches, and at the tips 
a little under an inch. The handles are 

lengthened tO Secure a better hold. 1 Straight forceps for ordinary use. 

1 It would appear that, in some quarters, the words "short" and "straight," as 
applied to the forceps, are admitted as synonymous terms. This, or (what is only 
too probable) some confusion in the text, seems to have led to the idea that the 
author of this work upholds the use of the short forceps. This he would beg to 
repudiate, and he refers to Fig. 150, and to its dimensions as now stated, in refuta- 
tion of what has been imputed to him by critics, who in other respects were gener- 
ous and indulgent to a fault. The instrument here described is, in point of fact, 
identical, or nearly so, with what is known in Ireland as Beatty's forceps, and is 
almost identical in measurement, although stronger in construction, with a straight 
forceps described by Dr. G-raily Hewitt some years ago. The young obstetric prac- 
titioner should have nothing to do with the short forceps, unless he should be so 
circumstanced as to have nothing better at hand. 



466 



THE FORCEPS. 



[CHAP. 



[The author's recommendation of the straight forceps will not be 
generally adopted in America. It carries us back to the days when 
Dr. Thomas C. flames, the first Professor of Obstetrics in the Univer- 
sity of Pennsylvania, advised the numerous students whom he taught 
to use no other than the short straight instruments of Haighton. If 
wo were to accept Dr. Irishman's statements as correct, the earnest 
teachings of Dr. Dewees, "the American Baudelocque ;" and of Dr. 
Hodge, his illustrious successor in the University of Pennsylvania, 
would pass for naught. The former of these great men introduced the 
long double curved forceps into use in America. The latter modified 
the instrument in a number of important particulars. 

In this country the straight forceps are scarcely ever used. The late 
Professor Charles 1>. Meigs recommended the short double curved in- 
strument of Professor Davis, of London, and for a long time it was a 
favorite with the graduates of the school in which the former taught. 
The inventor of these forceps, however, expressly 
1 '"•• 15L stated that they were only applicable to cases in 

which the head was arrested at the outlet or in 
the cavity of the pelvis, and that they could 
not he applied at the brim. Davis's instru- 
ment, or some modification of it, continues to 
be relied on in most cases by many experienced 
and successful practitioners. 

One of the most important improvements of 
this valuable instrument which has been made 
by any American accoucheur, is that of Professor 
Hodge, who has attempted to combine all the 
advantages of the various suggestions of others, 
while he rejected everything which he deemed 
objectionable. This forceps, its inventor claims, 
has the following advantages over those of 
others : 

1. Its weight is diminished (to seventeen 
ounces avoirdupois) without any diminution of 
its strength. 

2. The pelvic curve is such that the perineum 
cannot he dangerously pressed upon when the 
instrument is applied at the superior strait, 
while any loss of power which may result from 
this increased curvature, is compensated for by 
a bend of the handles in the opposite direction, 
which preserves the direct line of traction. 

3. The shanks are closely approximated, and 
occupy nearly parallel lines, one anterior to the 

other, until nearly at the point where they join the blades, when they 
separate abruptly. Thus undue stretching of the vulva and the danger 
of lacerating the perineum are prevented. 

4. The blades are of nearly the same width in all their parts, so that 
the fenestra? have the outline of an elongated oval rather than the 
kt kite" shape of those of the French and English instruments. This 




Davis's lb re ops. 



XXVIII.] 



HODGE S FORCEPS. 



467 



not only secures a firmer bold on the child's head, but allows the pa- 
rietal protuberances to jut through the opening, so that the blades 
occupy no space in the cavity of the pelvis. 

5. The surface of the blades which comes in contact with the child's 
head is curved not only from the handle towards the extremity, but 
likewise from side to side, as was suggested by Haighton. In this 
manner the tissues of the child are always safe, as there is always a 
flat surface in contact with them. 

6. The cephalic curve is slight at the extremity of the blades, and 
gradually increases as the shanks are approached for two-thirds of their 
length, at which place the space between the blades is two inches and 
a half. From this point the width diminishes quite rapidly until the 
shanks are reached. In this manner the force employed is equally 
distributed over the child's head, while the instrument is rendered less 



Fig. 152. 




Hodge's forceps. 



liable to slip, because as the head is compressed it will tend to glide 
deeper and deeper into the grasp of the blades. 

7. The blades are united by Siebold's lock, which gives it all the 
steadiness of the French, and is as easily adjusted as the lock of the 
English instrument. 

When made as directed by Professor Hodge, the whole length of 
the instrument is sixteen inches. From the lock to the extremity of 
the blades is nine and a half inches. The length of the blades proper, 



468 



THE FORCEPS. 



[chap. 



Fig. 153. 



in a direct line, is six inches. The extremities of the blades are half 
an inch apart when the handles are in contact, while the greatest width 
between the blades is two and one-half inches. 

This instrument has been extensively employed in this country 
through the influence of its eminent inventor. Still, the teaching of 
the Jefferson Medical College has always been in favor of some form of 
Davis's forceps. Professor Meigs, who so long occupied the chair of ob- 
stetrics in that school, and who for so many years was the contemporary 
teacher of Hodge, in Philadelphia, as has already been stated, recommend- 
ed Davis's short double-curved 
instruments to the large classes of 
students which annually gathered 
to be instructed by him. His suc- 
cessor, Professor Ellcrslie Wal- 
lace, has modified this instrument, 
making one with substantially 
Davis's blades and Hodge's han- 
dles. The whole length of the 
forceps in a direct line, from the 
extremity of the blade to the end 
of the blunt hook on the handle, 
is fifteen inches. From the ex- 
tremity of the blade to the lock 
is eight and one-half inches. The 
extremities of the blades are half 
an i nch apart. The greatest width 
of the space between these is about 
one-third of the distance from the 
shanks, and is two inches and a 
half. The fenestra? have the oval 
outline of the original Davis and 
the Hodge forceps, but the shanks 
are more closely approximated 
than in the former instrument. 
They are nearly parallel, and that 
of the female, occupies a position 
in front of that of the male blade. 
This is an important change, and 
insures the integrity of the peri- 
neum, so that the instrument can 
be applied high up in the cavity 
of the pelvis or at the superior 
strait, without endangering any of the mother's tissues. 

The editor has used Professor Wallace's forceps for the past decade, 
in both private and hospital practice, almost to the exclusion of the 
eclectic instrument of the late Professor Hodge. When the head is 
high up in the pelvic cavity, or at the superior strait, they are more 
easy of application, and hold more firmly than the instrument of 
Hodge. 

Dr. Albert H. Smith, the eminent lecturer on Obstetrics at the 




Wallace's forceps. 



XXVIII.] 



SMITH S FORCEPS. 



469 



Fig. 154. 



Nurse's Home in Philadelphia, in a discussion on the use of the obstetric 
forceps at the Obstetrical Society in that city, in 1872, announced his 
preference for the Davis forceps, because their grasp is more firm, and 
they slipped less easily than Hodge's. In the American Journal of 
Medical Sciences for July, 1869, he published a description of a modi- 
fication of this instrument, which adapts it to cases in which the head 
is high up in the cavity, or at the superior strait. The peculiarity of 
the instrument is that it is made portable by a joint in the handles, by 
which the forceps can be separated into two parts, and " one of the 
handles can then be joined to a vectis, and the instrument used either 
as a vectis or a blunt hook. A sepa- 
rate pair of short handles is provided 
for cases where the short forceps 
would be preferable, as where no 
compression is desirable. The con- 
nection is made by means of a pivot 
and socket joint about an inch below 
the lock, adjusting very firmly and 
readily by a spring-catch, raised in 
separating them by means of a con- 
cealed lever upon the inside of the 
handle. The instrument is thus ren- 
dered more portable without in the 
slightest degree impairing its strength. 
The blades are of the Davis pattern, 
and the lock a simple button, proved 
by experience to be the safest and 
most readily adjustable of any in use. 
The long handles for compression 
permit an approach of the blades at 
their widest part of two and a quarter 
inches ; the short handles for traction 
in ordinary cases only two and three- 
quarter inches. The jointed handle 
could be adapted to any pattern of 

blade desired. The whole set, taken to pieces, can be put in a leather 
bag nine inches in length and two and a half in width." 

The late Prof. George T. Elliot, of New York, used and recom- 
mended a forceps which is essentially a modification of the instrument 
used by the late Sir James Y. Simpson. The total length of the speci- 
men of Dr. Elliot's forceps, which we measured, is fifteen inches in 
a direct line from the extremity of the handles to that of the blades. 
From the lock to the end of the blades is nine inches. The greatest 
distance between the blades is three and a quarter inches, while the 
extremities of these are an inch apart. The blades are united by the 
English lock, and the handles are composed of steel and wood. In one 
handle is a bolt which, when screwed out by a burr in the handle, for 
that purpose, limits the compression exerted by the instrument to any 
extent desired by the operator. 

In 1872, Prof. F. M. Robertson, of Charleston, South Carolina, 




Smith's forceps. 



470 



THE FORCEPS. 



[CHAP. 



published a description of the forceps which he uses, and which is in 
reality a modification of Hodge's. The blades are those devised by 
Hodge, except that the pelvic curve is slightly increased. The blunt 
hook on the handles of Hodge's forceps has been abandoned, and the 
latter, which are composed partly of steel and partly of wood, have 
been reduced 2.3 inches in their length. The length of the shanks is 
also reduced .5 of an inch, making the entire length of the instrument 
from the extremity of the handles to that of the blades in a direct line 
13.5 inches. 

Dr. Robertson prefers that women should occupy the dorsal position 
during childbirth, and the chief advantage which he claims for his 



Fig. 155. 



Fig. 156. 





Elliot's forceps. 



Eobertson's forceps. 



modification of the forceps is that it can be applied without changing 
the position of the patient. 

The instruments of Hodge and Wallace were generally used in 
Philadelphia until about five years since, when Dr. William F. Jenks 
returned to this country after several years' sojourn in Europe. He 



xxviii.] Simpson's forceps. 471 

brought with him a pair of Simpson's forceps, accurately made accord- 
ing to the model of the famous Edinburgh Professor. Dr. Jenks's 
persistent advocacy of this instrument induced many of his friends to 
try it. The result is that it is rapidly growing into favor among Phil- 
adelphia obstetricians. The total length of Simpson's instrument, 
from the extremity of the blade to that of the handle, is thirteen and 
one-half inches. The distance from the lock to the extremity of the 
blade is eight and one-half inches in a direct line. The blades and 
shanks are therefore of precisely the same length as those of Wallace's 
forceps, but they are one inch shorter than the eclectic instrument of 
Dr. Hodge. The extremities of the blades are an inch and an eighth 
apart, the handles being in contact, or five-eighths of an inch more than 
either Hodge's or Wallace's forceps. The greatest space between the 
blades is three and a quarter inches, or three-quarters of an inch more 
than that of the instruments of Hodge and Wallace, and one inch more 

Fig. 157. 







Simpson's forceps. 

than the long forceps of Smith. The shanks are about two inches 
long, and run parallel to one another three-quarters of an inch apart. 
The blades are united by the English lock, which is made very loose, 
so that the handles have considerable play. This facilitates locking. 
The handles are composed of wood and steel, and at their upper ex- 
tremity terminate in hollowed transverse projections or shoulders, 
which enable the instrument to be firmly grasped. 

This is a fair description of the various models of forceps now in 
common use in America. Various other modifications are employed 
by individual practitioners. Whichever one of these varieties may be 
selected, it will fill the requirements under all ordinary circumstances ; 
whereas, if the recommendations of the author are followed, the physi- 
cian will be forced to have two pairs of forceps at hand, if he expects 
to apply them at the superior strait. When supplied with Hodge's, 
Wallace's, Smith's, or Simpson's instruments, the operator will find 
the short forceps entirely unnecessary. Any one of these can be ap- 
plied anywhere in the parturient canal. 

Several things have to be taken into consideration in the selection 
of a pair of forceps. From the descriptions of the various instruments 
in use it will be seen that they may be divided into two distinct classes : 
those which are forcible compressors, and those which have but little 
power to diminish the size of the child's head. In this first class may 
be included the instruments of Hodge, Robertson, Wallace, and Smith. 
Of these, the last is the most poAverful compressor, as the space be- 
tween the blades is only two and a quarter inches at its widest part, 
while the instruments of Hodge, Robertson, and Wallace measure two 
and a half inches in the widest part. On the other hand, the forceps 



•JL72 THE FORCEPS. [CHAP. 

of Simpson and Elliot possess but little compressing power, the blades 
of both having three and a quarter inches between them at their 
widest point. Of those varieties which may be styled powerful com- 
pressors the editor has always preferred the forceps of Professor 
Wallace. The advantages of these are the ease with which they are 
introduced, owing to the great pelvic curve, and the tightness of the 
grasp. Of the second class, Simpson's instrument, when properly con- 
structed, appears to us to be the best, and is the one which we now 
US e._p.] 

Cases requiring the use of the forceps are very variable in their 
general features, but most of them may be referred to one or other of 
the following groups. We may have, in the first instance, cases in 
which everything is normal save expulsive power, which may utterly 
fail as the period of delivery approaches: this failure of the vis a tergo 
is familiarly known as " uterine inertia," and from it arises, more fre- 
quently than from any other cause, the necessity for operative assist- 
ance. In another group, the operation is rendered necessary by a minor 
degree of pelvic deformity, at the outlet or in the cavity, — of which 
flattening of the sacrum is an example, probably of more frequent 
occurrence than is usually supposed. The application of the forceps, 
when the head is at or above the brim, is less frequently required, 
and is attended with special difficulties and dangers which will be duly 
considered. Any mechanical obstruction, however, whether of the 
hard or soft parts, including abnormal rigidity of any portion of the 
parturient canal, may be an unmistakable warrant for operative assist- 
ance. In occipi to-posterior positions, and in face presentation, the 
forceps may be found necessary either for rectification or direct ex- 
traction ; and, in convulsions, or any condition calling for speedy 
delivery, it may also be necessary to use the forceps if the labor 
has sufficiently advanced to admit of the safe application of the in- 
strument. Some of the rarer circumstances calling for the forceps 
have already been mentioned, such as certain exceptional cases of rup- 
ture of the uterus, placenta prsevia, or funis presentation. In cases of 
breech presentation, or after turning, it is frequently necessary to apply 
the forceps, when the trunk has been born, in order to extract the head 
from the soft parts and protect the child from suffocation. The instru- 
ment being specially constructed for application over the spheroidal 
cranium, is only applicable, as is evident, to a limited class of cases. 
For other presentations, which may require operative assistance, special 
mechanical aids must be sought. The necessity for operation by the 
forceps arises more frequently in primipane than in women who have 
already borne children. 

[Under many of these circumstances it is an important and difficult 
question to decide when to interfere. Authors generally point out the 
circumstances which warrant resort to the forceps, but few of them give 
any definite advice as to how long the powers of nature are to be trusted 
in a case of delayed labor. Denman, however, was explicit upon this 
point. His advice " that the head must rest immovable six hours 
upon the perineum before the forceps be resorted to," has often been 
quoted. This so manifestly limits the use of the instrument and cur- 



XXVIII.] USE OF THE FORCEPS. 473 

tails the power of the physician to relieve his patient, that the advice 
need not be refuted in this enlightened age. Others never resort to 
the forceps until the pains have ceased and the patient begins to show 
signs of exhaustion, becomes hot, thirsty, and has a rapid pulse; in 
short, until febrile reaction sets in. Such advice is scarcely in advance 
of the teaching of Denman, and indicates either ignorance of the value 
and powers of the forceps, or timidity in their use. 

We do not hesitate to assert that this instrument, when properly 
applied and skilfully manipulated, by an educated and judicious phy- 
sician, cannot possibly injure the mother. This fact cannot be too 
strongly insisted upon. As regards the child, it must be acknowledged 
that occasional injury may be inflicted upon its tissues. However, this 
rarely occurs in the hands of an experienced and skilful operator. 
Careless application of the instrument may be detrimental to both 
mother and child, but properly and scientifically used, it shortens and 
diminishes the suffering of the one, and may be the means of saving 
the lives of either or both. 

Therefore, instead of waiting in cases of delay until the mother shows 
symptoms of exhaustion, or until auscultation shows that the child's 
life is in jeopardy, the careful and educated physician will anticipate 
and prevent danger. It is a notable fact that those who resort to forceps 
most frequently are rarely compelled to use the perforator, and scarcely 
ever deliver a stillborn child, or lose a mother in childbed. The late 
Dr. William Harris, of Philadelphia, practiced obstetrics extensively 
for forty-six years, and used the forceps in about one out of every seven 
cases. For thirty years he did not lose a woman from labor or its im- 
mediate effects. Dr. Hamilton, of Great Britain, uses the forceps in 
one-seventh of his cases. He makes sure that the anterior lip of the 
uterus recedes before the descending head, and then if labor does not 
terminate spontaneously in two hours, he delivers with the forceps. 
The results of this practice are, that in one series of seven hundred and 
thirty-one consecutive confinements, there was not a single still birth. 
This result is truly remarkable. The maternal mortality, though not 
definitely stated, is said to have been satisfactory, That the mothers 
were not injured by the use of the instrument, may be inferred from the 
fact, that Dr. Hamilton did not have to use the catheter upon a puer- 
peral patient, in his own practice, during a period of thirty years. 

Dr. G. E. Francis, of Worcester, Mass., has recently reported a series 
of three hundred confinements, in which the forceps were used in one 
in every six cases. Of the three hundred women three died ; two from 
unavoidable causes, pulmonary thrombosis and blood-poisoning from 
erysipelas, and the other from exhaustion due to a a very long first 
stage in which no interference was permitted," so that '" by the time 
the os was dilated she was in a high fever." Of the three hundred 
and one children born, the author states that all were alive excepting 
four. One of these was destroyed by prolapse of the cord, one was a 
monster, and one was supposed to have died before labor commenced. 
The fourth appears to have been born alive, but it was premature, and 
died in a few hours. These results are certainly all that could be 
desired. 



474 THE FORCEPS. [CHAP. 

In a discussion upon the use of the forceps before the Obstetrical 
Society of Philadelphia in 1872, Dr. Albert H. Smith stated "that 
he had long made it his rule in normal pelves never to allow his patient 
to suffer long after the full dilatation of the os uteri had taken place." 

The editor long since adopted for his guidance the rule never to wait 
more than two hours after the progress of the labor had been arrested, 
no matter whether the delay was due to inefficiency of the pains or 
disproportion between the size of the head and the pelvis, and no mat- 
ter in what part of the parturient passages the head is arrested, whether 
it is at the superior strait, in the cavity, or at the outlet of the pelvis. 
The results of not a small experience in both private and public prac- 
tice, have only strengthened him in the belief that this rule of practice 
is a proper one, and diminishes the dangers of both mother and 
child.— P.] 

A2iplication of the Forceps. — Before, in any case, making the slightest 
attempt in this direction, we must be sure that neither the bladder nor 
rectum are distended, and this caution is specially required as regards 
the bladder, from which the contents must, if necessary, be withdrawn 
by the catheter. An essential condition is, according to all authorities, 
complete dilatation of the os, but some difficulty unfortunately seems 
to exist in determining what we are to understand by " complete dilata- 
tion." The cases which are undoubtedly most favorable for operation 
are those in which the os is absolutely obliterated or drawn up beyond 
the reach of the operator over the advancing head. But if we limit 
the employment of the instrument to these cases alone, we shall certainly 
withhold assistance in many in which we might deliver the woman 
with perfect safety. Obliteration of the os, or actual continuity of^the 
uterine with the vaginal canal, is no doubt desirable, but we must not 
admit as true the statements of those who tell us that it is essential to 
safety. To wait until the lip of the os can no longer be felt, as some 
have said, is to wait for what may possibly never occur; and, in like 
manner, if we accept the rule as perfectly correct that we are never to 
pass the blades of the forceps within the uterus, we may allow the 
period to pass at which we may, by prompt action, save the life of the 
child. 

Complete dilatation of the os is, indeed, in a sense, absolutely essen- 
tial ; and it is certain that a greater degree of dilatation is necessary for 
this than for any other of the operations for delivery. But complete 
dilatation, in the sense which we would attach to the term, does not 
imply that the anterior lip of the os has passed out of reach beyond the 
head, but merely such dilatation as will admit of the safe passage of the 
head. In many cases, then, we are justified in passing the blades 
partly within the uterus, and we apprehend that Dr. Ramsbotham's 
assertion is strictly correct when he affirms that the forceps may be 
used in some cases in which as much as a third part of the circular 
margin of the os uteri can be felt. There can be no doubt that, in a 
considerable number of cases, recession or retraction of the os, and 
especially of its anterior lip, does not occur immediately upon full 
dilatation, nor, it may be, for a considerable period thereafter. 

The possibility of feeling an ear has been very generally looked upon 



XXVIII.] CONDITIONS ESSENTIAL TO SAFETY. 475 

as an important and, by some, as an essential condition, in the absence 
of which we would never be justified in operating. That the ear may 
often be reached with ease, when the other operative conditions are 
fulfilled, is undoubted ; and, in cases in which we are only called in 
when a large caput succedaneum has in sOme measure obliterated the 
landmarks on the surface of the cranium, it is really important that 
we should seek for and observe the ear, with the view of determining 
the exact position of the head. But to accept this as a rule for our 
guidance in every case, is both unnecessary and improper, as the ear, 
in some cases in which we may hold the operation to be perfectly justi- 
fiable, can only be reached with difficulty, or with an amount of violence 
which may greatly aggravate the sufferings of the patient. To these we 
might add other conditions, which have been prescribed as essential to 
the safe performance of the operation, but which have deservedly fallen 
into neglect. 

The forceps must be applied directly to the surface of the child's 
head, and it is therefore absolutely necessary that the membranes be 
ruptured should this not have already spontaneously occurred. We 
have been summoned with a view to delivery by the forceps in a case 
in which it was stated that the os was fully dilated, although it turned 
out that the os was still very slightly dilated and only reached with 
difficulty in the posterior part of the pelvis, the thin uterine wall being 
still extended over the surface of the scalp. Such a condition could, 
with ordinary care, scarcely lead to an error in practice, but the possi- 
bility of a mistake should nevertheless be borne in mind by the inex- 
perienced. 

If possible, but with exceptions to be afterwards noticed, the blades 
should be applied to the sides of the child's head. To do this with 
accuracy, it is necessary that the actual position of the head be made 
out with perfect certainty. This may be ascertained, as has been ex- 
plained in a former chapter, by a careful examination of the sutures 
and fontanelles, and of the relation which these parts bear to the pelvic 
canal ; and, as there are four possible cranial positions, we must first 
be sure with which of them we have to deal, before we take the instru- 
ment into our hands. It is only, as we have said, when exceptional 
difficulties exist that we require to examine the ear. No one, there- 
fore, is qualified to attempt delivery by the forceps unless he is familiar 
with the laws which regulate normal parturition ; and there is, in fact, 
no operation or contingency in midwifery practice, in which a thorough 
knowledge of the mechanism of labor, in all its details, is so essential 
as this. It is unnecessary to inform any one familiar with the details 
of normal parturition, that the method of application will depend upon 
the situation of the head. In proportion to the proximity of the head 
to the external parts the movement of rotation will be found, in the 
ordinary position, to have occurred ; and, therefore, the nearer it is to 
the outlet, the more do we require to apply the blades in the transverse 
diameter of the pelvis, in our endeavor to adjust them to the sides of 
the head. When, however, the head is higher, its position is more 
decidedly oblique, and, even at the outlet, a little of this obliquity still 
obtains ; so that, to insure their application to the sides of the head, 



476 THE FORCEPS. [CHAP. 

we must apply them in the opposite oblique diameter to that in lohieh the 
child's head lies. 

Having satisfied ourselves as to the position of the head, and that 
the conditions exist which warrant the performance of the operation, 
we prepare the forceps by warming and greasing the blades. The 
patient, who lies in the ordinary midwifery position, should be carried 
quite to the edge of the bed, so that her hips may even project a little 
over it, and she is then to be brought, with due caution, under the 
influence of chloroform. We should be perfectly satisfied with her 
posture before commencing the operation, as to change her position 
after one blade has been introduced is not free from risk. If the head 
is at the outlet and resting on the perineum, the blades are to be in- 
troduced so that the handles shall look forwards under the arch of the 
pubis; if rotation has not yet occurred, and the head is consequently 
in the lower part of the cavity, they will, with reference to the erect 
posture, look doivnwards ; and, if the head is higher in the pelvis, they 
will look more or less backwards in the direction of the perineum. If, 
however, it is still high in the pelvis, or at the brim, we should use the 
double-curved long forceps ; for, our object being to apply extracting 
force in the axis of that part of the pelvis which the head occupies, we 
must discard the straight forceps so soon as the shanks of the blades 
come to press upon the fourchette. This we do for various reasons, 
to be afterwards more particularly explained in connection with the 
subject of the double-curved forceps, not the least of which is the 
danger to the integrity of the perineal tissues which would accrue in an 
attempt to pull the head backwards in a direction even approaching 
to the axis of the brim. 

Let us suppose the head to be in the position which in seventy per 
cent, of cranial presentations it occupies, — in the right oblique diameter, 
with the forehead towards the right sacro-iliac synchondrosis, and the 
occiput to the left foramen ovale. The blades, in this case, are to be 
passed in the direction of the left sacro-iliac synchondrosis and the 
right foramen ovale, or, in other words, to the poles of the left oblique 
diameter of the pelvis. With reference to the position of the woman, 
we speak of the " upper" and " lower " blades. It is of no great im- 
portance which of these blades is first introduced, but it is proper that 
the operator should have a definite plan of procedure, which he may 
adopt in every case. If he introduce, as we are in the habit of doing, 
the lower blade first, he grasps one of the blades with the fingers of his 
right hand as he would a catheter, and holds it for a moment diago- 
nally across the breech of the woman, with the concavity of the blade 
turned towards her, the point downwards and to the left, the handle 
upwards and to the right. If thus held, it will correspond to the left 
oblique diameter, and from this it should not deviate or twu'st in any 
way during its introduction. Two or three fingers of the left hand, 
which have been duly anointed, are then to be passed into the vagina, 
over the left ischial tuberosity, in the direction of the corresponding 
sacro-sciatic ligaments, with the palmar surface upwards, until the head 
is reached. The blade is then passed along the fingers, and, if the os 
is still distinguishable, it is to be carefully guided within it. If the 



XXVIII.] INTRODUCTION OF THE LOWER BLADE. 



477 



handle is now gradually depressed, and at the same time gently pushed 
onwards, it will generally glide over the convex surface of the cranium 
without the slightest difficulty or danger. Should the blade turn or 
twist in the direction either of the hollow of the sacrum or of the fora- 



FlG. 158. 




Introduction of the lower blade. 

men ovale, it is on no account to be replaced forcibly, but is to be par- 
tially withdrawn by raising the handle, and reintroduced with greater 
care. The handle is then carried towards the perineum, and intrusted to 
an assistant while the introduction of the upper blade is being effected. 
The operator should take the second blade with his left hand, so that 
it diagonally crosses the breech as before, but with the point above and 
to the right, and the handle downwards and to the left. The fingers 
of the right hand are then passed in the direction of the right foramen 
ovale until the head is reached, and along their palmar surface, which 
is turned downwards, the blade is then to be introduced. The reason 
for bringing the woman quite to the edge of the bed now becomes ob- 
vious, as it is only in this way that the handle of the upper blade can 
be sufficiently depressed to admit of its easy introduction. This blade 
is introduced, as will be observed, in front of the lower blade, as it is 
only in this way that the two parts of the forceps will lock. 1 The 
hand is now to be steadily raised, when, under the direction of the 
fingers, the blade will glide over the right side of the child's head. An 



1 We have frequently observed that students who may be practicing these details 
with the machine and phantom commit the error of passing the second blade with- 
out any reference to the direction of the lock in the first. This error cannot possi- 
bly be committed in practice if the directions here laid down are observed. 



478 



THE FORCEPS. 



[CHAP. 



excellent guide during this part of the operation is derived from an 
observation of the inner or metallic surface of the handle, which should 



Fig. 159. 




Introduction of the upper blade. 

remain parallel with the corresponding surface of the lower blade, and 
the earliest deviation of the blade from its proper course will be found 
in an inclination of this surface to one side or another. Should this 



Fig. 160. 




The forceps applied. 



occur repeatedly, after partial removal and reintroduction of the blade, 
it may be advisable to withdraw the lower blade, and introduce it with 
reference to the other, as there is the possibility of a mistake having 
been committed as to the position of the head, and it is besides a mat- 
ter of far greater importance to have the blades exactly opposite to 



XXIX.] THE FORCEPS. 479 

each other, than to have them accurately adapted to the transverse 
diameter of the head. The best test of a proper application of the for- 
ceps is the perfect locking of the blades after their introduction. Fig. 
160 shows the blades as adjusted for the first position, the head being 
in the pelvic cavity, as is indicated by the direction of the handles. 
The blades being separated by the transverse diameter of the head, the 
extremities of the handles are about an inch apart. 

When the head occupies the second cranial position, the blades are 
to be applied to the poles of the right oblique diameter. The lower 
blade is therefore introduced in the direction of the left foramen ovale, 
from which point the handle is first directed upwards and to the left, 
and then depressed downwards and to the right. The upper blade is 
then introduced in the direction of the right sacro-iliac synchondrosis, 
taking care that it is passed in front of the lower blade, and that the 
metallic surfaces of the handles retain their parallelism as before. In 
third positions, the forceps must be applied in exactly the same way as 
when the head is in the first ; and in fourth presentations as for the 
second. 



CHAPTEE XXIX. 

THE FOKCEPS (Continued). 

ACTION OF THE FORCEPS : 1, BY COMPRESSION ; 2, BY TRACTION ; 3, BY DOUBLE-LEVER 
ACTION— MODE OF EXTRACTION: MANAGEMENT AND DIRECTION OF THE HAN- 
DLES AT VARIOUS STAGES OF DELIVERY — DELIVERY BY THE FORCEPS IN OC- 
CIPITO-POSTERIOR POSITIONS: ROTATION BY THE FORCEPS: EXTRACTION WITH 
THE FOREHEAD FORWARDS — THE " LONG FORCEPS " — REASONS FOR PREFERRING 
THE PELVIC CURVE IN THIS OPERATION — DESCRIPTION OF THE INSTRUMENT — 
CASES IN WHICH THE LONG FORCEPS IS APPLICABLE — DIRECTIONS FOR THE 
OPERATION : BLADES TO BE APPLIED TO THE SIDES OF THE PELVIS : MODE OF 
INTRODUCTION OF THE LOWER AND UPPER BLADES: RELATION OF THE BLADES 
TO THE SURFACE OF THE CRANIUM — USE OF THE FORCEPS IN PRESENTATIONS 
OF THE FACE — PROCEDURE WHEN THE HEAD IS RETAINED AFTER EXPULSION 
OF THE TRUNK — MODIFICATIONS OF THE INSTRUMENT : ZIEGLER'S, RADFORD'S, 
AND OTHER FORCEPS. 

The forceps acts mechanically in three different ways in effecting the 
object which we have in view : by compression, by traction, and by a 
double-lever action. In so far as Compression is concerned, a certain 
degree of this is essential, in order to grasp the head with the blades, 
which otherwise would slip off, or would only be precariously main- 
tained in their position, under certain circumstances, by the pressure of 
the walls of the parturient canal. But, by compression, something more 



430 THE FORCEPS. [CHAP. 

is implied than mere grasping; for by it, as is obvious from the yield- 
ing nature of the sutures and fontanelles, the actual diameters of the 
cranium may be materially diminished. It is to be remembered, how- 
ever, that the forceps is usually applied to that portion of the cranium 
which is least subjected to pressure, and that, therefore, as a rule, little 
is to be gained by diminishing these diameters. We may, in fact, 
assume that the pressure which is necessary to insure such a grasp of 
the head as may render it impossible for the blades to slip under mod- 
erate efforts, will effect all the compression which is desirable. Many 
recommend that a piece of cord or tape should be firmly tied round the 
handles in order to keep up sustained pressure on the cranium, and it 
is for this that the depression near the extremities of the handles, 
which is characteristic of all English forceps, is intended. This mode 
of procedure is not to be commended, as such serious and sustained 
pressure may endanger the life of the child. The power exercised by 
the hands of the operator, if only the handles are of proper size, is 
quite sufficient for our purpose, and being necessarily intermittent, is 
free from the danger which attaches to continuous pressure upon struc- 
tures so delicate and important as are contained within the cranium. 
Sometimes, when it is necessary to use very considerable force, the full 
extent of possible compression must be resorted to, but this more with 
the view of maintaining a secure hold than of gaining much by mere 
compression. In such a case, the corner of a towel which has been 
dipped in water may be tightly bound round the handles at the depres- 
sion alluded to, when the remainder of the towel being wrapped round 
the handles will give a better hold and more power; but, when this is 
done, the pressure should always be relieved during the intervals be- 
tween the pains, or when at any other time we make a periodical pause 
in our extractive efforts. The amount of compression which is safe 
will depend in no small measure on the construction of the forceps ; 
and, in an instrument, such as are many of those of French manufac- 
ture, with an interval of half an inch only between the tips, the pressure 
will certainly be attended with more risk than when these are, as they 
should be, an inch or nearly so apart. This is done with the view of 
avoiding — what is always dangerous — continuous pressure on the child's 
head ; and, for the same reasons, if pains be absent, our efforts at ex- 
traction should be intermittent so as to imitate as closely as possible 
the normal process. 

The forceps acts also by Traction ; but this force is not applied alone, 
as in drawing a cork from a bottle, but in combination with the third 
mode of action of the instrument, — viz., that of a Double Lever. The 
forceps, as almost invariably constructed with the English or other 
similar lock, is composed of two levers — the fulcrum of each being the 
lock. This enables us, by a swaying movement of the hands, to apply 
extracting force, partly by leverage and partly by traction, to each side 
of the head successively, without the danger which attaches to the single 
lever or vectis, where it is necessary to find a fulcrum in some part of 
the pelvic wall. 

When the blades have been adjusted to the satisfaction of the operator, 
he now proceeds to the actual operation of extraction. As his object 



XXIX.] EMPLOYMENT FOR RECTIFICATION. 481 

should, in most cases, be rather to aid than to supersede the natural 
efforts, he must merely assist the pains should they be present, and 
pause when his assistant informs him that the uterine action has ceased. 
This leads us to observe, that, if it be practicable, the assistance of 
another practitioner should always be obtained ; for not only is there 
thus a division of responsibility, but the operator has the great advan- 
tage of efficient and intelligent aid, to which he can trust for the man- 
agement of chloroform, the steadying of the uterus, and many other 
points of detail, which it is impossible to obtain at the hands of those 
who are ignorant or inexperienced. 

When the action of the uterine fibres has ceased — as in cases of 
complete inertia — he should imitate nature by applying extracting force 
at intervals corresponding to the ordinary duration of natural pains. 
The handles should be grasped by both hands, two of the fingers of one 
hand being passed up so as to impinge upon the head. The object of 
this is to ascertain the earliest indication of slipping of the blades, 
which is always more apt to occur when the distance between their 
extremities is more than an inch. So soon as he feels that his fingers 
are leaving the surface of the scalp under the influence of his efforts, he 
knows that the instrument is losing its hold. The blades should then 
be disarticulated and pushed back to their original position ; and, upon 
renewed efforts, he makes use of a little more compression, thus striving 
always to effect the dislodgement of the head with as little of actual 
force as may be necessary. The force should be applied as nearly as 
possible in the direction of the axis of that part of the pelvic canal 
within which the head lies ; and the operator should act by combining 
steady traction with a swaying motion of the handles from side to side. 

If the head is by these efforts dislodged from the situation in which 
it has been arrested, and moves downwards into a lower plane of the 
pelvis, this may, in the presence of efficient pains, be all that is re- 
quired, as nature will often in such cases complete the delivery. It is 
better, however, at this stage, not to withdraw the blades, but merely 
to disarticulate them, and, leaving them in contact with the head, 
watch the result. If the head now moves satisfactorily with every 
pain, they may be entirely withdrawn ; but, so long as there seems a 
probability of further assistance being required, it is better to leave 
them than to run the risk of having again to apply them at a more 
advanced stage of the labor. If it is a case of inertia, or when there 
is obvious obstruction at the outlet, our efforts must be continued at 
intervals as before ; resting satisfied with a very gradual advance, and 
never (unless under exceptional circumstances, when rapid extraction 
is imperatively demanded) striving for a speedy termination of the 
case, which might endanger the perineum, and the other soft structures 
which nature in normal cases very gradually distends. 

The direction which, in labor, the head naturally takes is always to 
be kept in mind. As it descends, therefore, if it has originally been in 
the cavity when the blades were introduced, the handles are to be 
carried forwards under the arch of the pubis, and at the moment of 
birth, are to be raised in front of the symphysis. It is at this moment 
that precipitation or violence of any kind is so apt to lacerate the 

31 



482 THE FORCEPS. [CHAP. 

perineum, so that we •should, by every means in our power, closely 
imitate the process by which nature so admirably effects the dilatation 
of this structure. It is usual to practice what is called support of the 
perineum, in forceps as in ordinary cases; but in such means, as a 
preventive of laceration, we have, for reasons already stated, no con- 
fidence whatever.. As the head passes from the cavity to the outlet, 
the natural movement of rotation is not to be forgotten. It is not, 
indeed, necessary that we should attempt artificially to produce this 
rotation. Under the influence of the ordinary causes, nature will effect 
it at the proper time, whereas we might only do harm by misplaced 
efforts before that time has arrived. Still, it is proper that we should 
watch the first indications of rotation, and, in our subsequent endeavors, 
" humor" the blades so as in every way to encourage it. 

The situation on the sides of the child's head which corresponds to 
the blades, varies considerably, and will depend, in some measure, on 
the degree of moulding, or elongation, which may have occurred. 
When successfully applied, so as to obtain the best possible hold, the 
tips of the blades will be found to have passed over the ears, and to 
have grasped the soft parts of the cheek beyond the zygomatic arch. 
In not a few cases 1 , however, and especially in those in which the for- 
ceps has been used before the head has attained the perineum, they do 
not reach so far, and in these the point attained will be marked by a 
depression in the temporal region above the zygoma. Beyond the 
depression just mentioned, the injury inflicted upon the soft parts of 
the child should be very trifling, even in severe cases. A certain 
amount of discoloration, from bruising, is sometimes noticed, but this 
disappears in the course of a few days. 

In the third and fourth, or occipi to-posterior positions, the difficulties 
which we encounter are often much more formidable. These difficulties, 
it is to be remembered, probably depend entirely on the faulty nature 
of the position. Our first attempts, therefore, should be to remedy 
these positions, by promoting the rotation which would bring the occi- 
put forwards. Having failed in our attempts to induce this rotation 
by the fingers, with or without the vectis, in the manner formerly de- 
scribed (see Chap. XVIII), we should always try to effect rotation by 
the forceps, previous to attempting direct extraction. Very special 
care is here necessary, as a moment's consideration will show, to dis- 
tinguish between the two occipito-posterior positions. If, for example, 
we should mistake the third position for the fourth, we would apply 
our rotating force so as to move the occiput from right to left in an 
attempt to reduce it to a first position, with the result, if we moved 
the head at all, of forcing it in the direction of the conjugate diameter, 
and thus making matters worse, instead of better. If, however, we 
are confident in our diagnosis, we have only to remember that third 
positions rotate naturally into the second, and fourth into the first, 
which at once points to the direction in which alone rotatory force can 
safely be expended. Dr. Tyler Smith says that we should rotate during 
the process of extraction ; but it is better that we should, in the first 
place, attempt simple rotation, and then, if that fail, combine rotation 
with extraction. If we succeed in effecting rotation, the case, left to 



XXIX.] 



LONG FORCEPS. 



183 



we fail, it will 



-a matter of difficulty 



nature, will terminate in the usual way. But, should 
be necessary to extract directly, without rotation 
always, and sometimes of impossibility. 

In delivering by the forceps, while the head remains in an occipito- 
posterior position, care must he taken to conduct the operation with a 
due regard to the manner in which nature effects delivery in such cases. 
If we attempt to drag the head forwards under the pubic arch, we will 
probably fail ; so that we should direct our efforts so as to get the occi- 
put over the perineum, — as it is only in this way that the occipito- 
mental diameter can be released, — and the forehead is then suffered to 
sweep backwards from behind the symphysis. The great danger is rup- 
ture of the perineum, which, in some instances, it will be almost im- 
possible to avoid ; but, when the pelvis is of good size, the difficulties 
attending delivery in such a posi- 
tion are by no means so great as FlG - m - 
might be supposed. 

The Long Double-curved For- 
ceps. — Whatever opinion may be 
entertained as to the propriety of 
employing the forceps with a 
double curve in all cases, without 
exception, we have no doubt that 
the long forceps, as applicable to 
cases where the head is at or 
above the brim, can only be used 
with safety when constructed on 
this principle. The objection to 
the long straight forceps in this 
situation is pretty obvious, if we 
reflect that extraction, exactly in 
the axis of the brim, is impossi- 
ble, as the line representing that 
axis passes through the coccyx, 
or even the lower part of the sa- 
crum. It is not, indeed, until 
the head has fallen well into the 
cavity, that it may be supposed 
to occupy a plane the axis of 
which passes in front of the peri- 
neum. Not even with the pelvic 
curve can Ave pull directly in the 
axis of the brim, but we are able 
more nearly to approach to what 
is desiderated, and, what is much 
more important, to do so with 
comparative safety. If the 
straight forceps is used at the 
brim, not only do we pull the head too much forwards, but we do so 
to the imminent danger of the perineum, against which the shank of 
the blades is pressed. And, if we overcome the first resistance, the 



m 



Forceps for application at the brim. 



484 THE FORCEPS. [CHAP. 

widening of the blades as they descend exposes this structure to ever- 
increasing danger as the child descends, for it is not till the head reaches 
the lower third of the cavity that we can bring the handles forwards. 
This risk to the perineum is, no doubt, much lessened, if we use an in- 
strument in which the shanks are approximated for some distance, so 
that the curve of the blades springs from a point several inches from 
the lock, as in a modification of Beatty's forceps, which has been very 
commonly used. 

In the construction of this variety of long forceps, bearing in mind 
the rule already laid down, our first point is to insure strength without 
clumsiness. There is good reason to believe that the neglect of this 
precaution has been the cause, in many instances, of the instrument 
slipping again and again. There is no necessity for the blades, if of 
proper material, to be of great thickness, but the handles should always 
be large, of sufficient size, indeed, to be firmly grasped by both hands. 
Endless varieties and modifications of the long curved forceps have 
been devised, and it is but natural that every operator should prefer 
his own. The instrument shown in Fig. 161, is somewhat similar to 
what is known in this country as Simpson's forceps, which was adapted 
by him from the pattern of that used by Naegele and other German 
accoucheurs. The joints are made so loose as to admit of very slight 
lateral motion or overlapping, and below the lock there are transverse 
rests which give more power to the hands; "the long forceps/' as 
Simpson observes, " being only properly used as an instrument of 
traction, not of compression." The length of the instrument which 
we have represented is sixteen and a half inches, bjeing ten and a half 
inches from the lock to the tip of the blades, and six inches for 
the handles. The measurements between the blades should be the 
same as those of the medium-sized instrument above described, and 
the fenestra? about five and a half inches in length. The instrument 
is thus, as it is believed, both longer and of greater strength than those 
which are generally employed by English practitioners. It is, we be- 
lieve, inferior in efficiency to none, and, if used with due caution, equal 
in point of safety to any. No one should, however, under any cir- 
cumstances, take such an instrument into his hands without a sense of 
responsibility much greater than attaches to the ordinary operation. 

The long forceps, in the sense in which we employ the term, is 
applicable to cases in which the head will not enter the brim or descend 
beyond the upper part of the cavity. The cases which are held to 
warrant its employment are chiefly those in which the head is arrested 
at the brim by reason of moderate contraction of the conjugate diameter. 
Great care must therefore be taken, in the first instance, to ascertain 
the degree of deformity, and to make sure that the case is really one 
in which the forceps may be used with a reasonable prospect of success ; 
for, if not, nothing can be more irrational than to subject the woman 
to the not inconsiderable risk which attaches to this operation, even 
under the most favorable conditions. When the child is dead, and the 
estimated difficulty in extraction is considerable, most accoucheurs 
would prefer to deliver by craniotomy; but if, on the contrary, there 
is evidence of the child being alive, nothing can be more repugnant to 



XXIX.] SCOPE OF LONG FORCEPS. 485 

the feelings, than the idea of an operation which deliberately destroys a 
life, and we will naturally prefer any procedure which may give the 
child a chance. To yield too far to this inclination would, however, 
be manifestly wrong, for the mere fact of the child's life need not enter 
into the calculation when it is obvious that it must, sooner or later, be 
sacrificed. Our whole attention, in such a case, should be centred in 
the mother, in whose interests, therefore, we should decide upon that 
operation which is likely to subject her to the least possible risk. 

But it is not against craniotomy alone that the long forceps may be 
balanced, for there are cases in which the question for decision is 
between the forceps and turning, as will be better understood when 
we come to consider the conditions under which we have recourse to 
the latter operation. It has been said that the forceps is a " child's 
operation," but we would take a very narrow and improper view of 
the scope of the instrument did we conclude that it was always so, and 
that it was inapplicable in the interests of the mother. The results of 
craniotomy are, according to Churchill, about one maternal death in 
five, and we may be sure that when the head is high in the pelvis the 
figures will be more unfavorable still. Nothing can be more absurd, 
therefore, than to assume that, in so far as the mother is concerned, 
craniotomy and the long forceps stand to each other in the relation of 
safety and danger; and yet it would almost seem that this was the 
idea which prompted many, even in modern times, to declare in favor 
of the former. 

The operation by the long forceps is one to which, as a rule, a 
considerable amount both of difficulty and danger is attached. This 
arises from the peculiar circumstances of the case, as compared with 
the ordinary forceps operation. There can scarcely be a stronger con- 
trast than between a case requiring the application of the ordinary 
forceps, when the head lies upon the perineum, and is arrested by 
simple inertia, and one in which a contracted brim prevents the head 
from entering the pelvic canal. In the one, we have the operation in 
all its details so thoroughly within our control, that we almost cease 
to look upon it with the slightest apprehension. In the other, we are 
operating comparatively in the dark, and at great mechanical disad- 
vantage ; we have to subject, to an extent which we cannot fully be 
aware of, delicate textures to violent compression ; we have to drag 
the head through the whole length of the pelvic canal instead of merely 
disengaging it from its proximal extremity ; and, finally, we have to 
determine between the amount of actual obstruction and the degree of 
justifiable force, with a nicety upon which success or failure will depend. 
Is it, then, to be wondered at that the operation is looked upon with 
apprehension as one beset with difficulties and dangers ? 

While we freely admit that the objections with which delivery by 
the long forceps is beset are in themselves sound, we must, at the same 
time, express our conviction that they have been in some degree ex- 
aggerated, and that to a greater extent by British than by Continental 
and American obstetricians. We see no reason to doubt that, when 
skilfully and warily employed, the best results will, in many instances, 
follow from its use — the one essential element which, above all others, 



486 THE FORCEPS. [CHAP. 

will contribute to success, being a careful selection of proper cases. It 
is now very generally believed, by those who have had the greatest 
experience, that a large proportion of the unfortunate results depend 
upon improper instruments, and especially upon the use of such as are 
deficient in power. The observations which, on this point, we have 
already quoted from Dr. Barnes apply here with peculiar force. Power 
and control are correlative factors towards the attainment of the result 
which we desire, and if there is a deficiency in the former we can have 
but little confidence in the issue of the case. 

[The dread of the operation with the long forceps, spoken of by the 
author, is one which is not shared by American obstetricians. No one 
can doubt that if arrest occurs at the inferior strait or low down in the 
cavity of the pelvis, the application of the forceps is less difficult than 
when the progress of labor is checked with the head well up in the 
cavity, or at the brim. But even under the latter circumstances, the 
forceps are constantly used in this country, and many prefer them to 
version, even when the head is movable. It should always be remem- 
bered that when skilfully and properly used the instrument cannot 
injure the mother. — P.] 

As regards the mode of application, the long forceps differs in many 
essential particulars from the other. Exceptional cases may no doubt 
occur, in which the forceps is applied at the brim to effect delivery, 
which is called for in consequence of inertia, haemorrhage, and the 
like; but in such cases (in which we may assume the pelvis to be of 
normal dimensions) the operation of turning will genei'ally be pre- 
ferred. Delivery by the long forceps may practically be considered as 
an operation in which the head is arrested by reason of contraction of 
the pelvic brim. Our object, then, is, not to apply the blades in the 
opposite oblique diameter of the pelvis to that occupied by the child's 
head, so as to secure their adaptation to the sides of the cranium, but 
rather to introduce them with special reference to the pelvic walls, so 
as to be sure that each passes along the side of the pelvis, and is thus 
opposite to the other in or near the transverse diameter of the brim. 
When the head is still above the brim, it usually occupies, as we have 
seen, a position which is more transverse than oblique, and the effect of 
conjugate contraction at this part is to maintain that position even after 
the head has actually engaged in the brim. Were we here to follow 
the usual rule, and did we succeed in applying the blades in that way, 
their grasp would be in the conjugate diameter, and in every effort we 
would run the risk of subjecting the soft parts of the mother to inju- 
rious pressure between the blades and the poles of the conjugate measure- 
ment — the chief danger being posteriorly against the projecting sacral 
promontory. Consequently, we must discard all preconceived ideas 
and rules, and pass the blades in the direction in which there is most 
room. 

[The discussion of the vexed question, whether the forceps should be 
applied in relation to the pelvis or the child's head, demands more than 
the passing notice given it by the author. Most American authorities 
teach that the forceps should be applied to the sides of the head if it is 
possible to do so. Hodge, Elliot, and others, however, recognize the 



XXIX.] USE OF THE FORCEPS. 487 

fact that this may be difficult or impossible when the head is transverse 
at or below the superior strait. On account of the danger of wounding 
the bladder and other delicate tissues, they advise that the blades be 
applied obliquely, one over the brow and the other over the opposite 
side of the occiput. Drs. Goodell, A. H. Smith, and Ell wood Wilson, 
of Philadelphia, all assert that the blades should always be applied to 
the sides of the child's head, no matter what may be its position in the 
pelvis, nor at what stage in labor extraction is attempted. An equally 
radical, but opposite opinion, has been assumed by the author, Barnes, 
and others, in Great Britain, and by German obstetricians in general, 
who assert that the position of the head should be practically disre- 
garded and the forceps applied in relation to the pelvis. Among 
American authors, these views have been adopted by Dr. C. C. P. 
Clarke, of Oswego, N. Y., and they have been taught and practiced 
in Philadelphia by Dr. W. F. Jenks and the editor for the past six or 
seven years. 

It will at once be seen that this is a very important question, not 
only as regards the success which follows the use of the forceps, but 
also as regards the convenience and comfort of the operator. It is 
manifest that if the position of the child's head can be safely disregarded, 
that the forceps are much more easily introduced. 

In order to decide this question it will be necessary to study the 
peculiarities of construction and action of the instruments employed, 
as well as the mechanism of the birth of the head in delayed labor 
from contraction of the pelvis. In describing the various varieties of 
forceps used in this country, it will be remembered that they were 
divided into two classes, those which are forcible compressors, and those 
which are possessed of but slight compressing power. In the first class 
are the instruments of Hodge, Robertson, Wallace, and Smith. These 
are all constructed with the idea of developing this force to a consider- 
able degree. Prof. Hodge, in his lectures and writings, strongly advo- 
cated a resort to compression in order to diminish the size of the child's 
head, so as to bring it through the contracted pelvic diameters. Now, 
adopting the rule that the forceps should always be applied to the sides 
of the head, it is the biparietal diameter which is shortened by this 
pressure. It is an acknowledged fact, also, that in cases of contraction 
of the brim, the head does not enter the pelvis with the biparietal in 
one of the oblique diameters, but in the conjugate of the pelvis. Hodge, 
Elliot, and others agree with Simpson, that it is dangerous to attempt 
to apply the instrument to the sides of the head under these circum- 
stances. Hodge also admits the fact that it is often very difficult to 
effect this when the head is driven down into the pelvis intone of the 
oblique diameters. He admits that the introduction of the blades is 
more difficult under these circumstances than when the head is at the 
superior strait. Dr. Ramsbotham, although an advocate for the appli- 
cation of the forceps to the sides of the head, acknowledged, in 1862, 
that he had " for many years been accustomed, however low the head 
maybe, to introduce the blades within each ilium, because they usually 
pass' up more easily in that direction." 

It is therefore apparent that the highest authorities who advocate the 



488 THE FORCEPS. [CHAP. 

cephalic application of the forceps, recognize that the rule is not uni- 
versal in its application, and Ramsbotham may be said to have practi- 
cally abandoned it. Those who favor the cephalic application assert 
that unless the head is grasped in its biparietal diameter, compression 
increases rather than diminishes the difficulty. It is to be remembered 
that the advocates of this opinion use forceps which are powerful com- 
pressors. The blades of Smith's, for example, are only two and a 
quarter inches apart at the point where the space between them is widest. 

The use of such instruments as these, the editor believes, is based 
upon a false notion of the mechanism of labor in cases of contraction 
which admit the use of the forceps. That compression will diminish 
the diameters of the foetal head, no one can doubt, but if flexion is per- 
fect, this does not result in flattening of the cranium between the resist- 
ing portions of the pelvis which grasps it, so much as in elongation of 
the head, increasing its fronto-mental diameter, a fact to which Barnes 
has directed attention. Under these circumstances, traction made with 
a properly constructed instrument, applied to the sides of the pelvis, 
aids the moulding of the head by supplying the deficient portions of 
the circle. Thus the elongation of the head is more rapidly effected, 
and the duration of labor shortened. 

If flexion is not entirely perfect, the head does not pass the brim of 
a contracted as it does that of a normal pelvis. It is to be remembered 
that the figure-of-eight pelvis is comparatively rare. In most cases the 
deformity is due to an abnormal prominence of the sacral promontory. 
The anterior margin of the pelvis preserving, as it does, its natural 
rounded contour, would allow the head to pass if it did not meet with 
resistance from the sharp point of the projecting promontory. The 
result is, as Barnes has shown, that in labor under these circumstances, 
" the promontory possesses a like importance at the brim or entry of 
the pelvis to that which the symphysis pubis possesses at the outlet. 
The promontory is a turning-point — a centre of revolution of the head, 
just like the symphysis. The curve round the pubis, which Cams 
described, has its counterpart in a curve round the promontory. In 
ordinary labor, with a well-constructed pelvis, the head enters the 
pelvis, and reaches nearly to the floor without deviating much from the 
straight line which represents the axis of the brim. Thus it enters its 
orbit, the circle of Cams, at once. 

" But a projecting promontory, involving, as it does commonly, a 
scooped-out sacrum below, disturbs this course. The promontory must 
be doubled. I propose to call this curve the curve of the false jyromon- 
tory." 

If the degree of contraction is great, the rounding of the projecting 
base of the sacrum may indent and even fracture the cranium. These 
injuries generally occur just anterior to the ear, or in front of the bi- 
parietal diameter, which is the one that is lessened by applying the 
forceps to the sides of the head. 

These facts point to the conclusion that the application of the instru- 
ments in the manner generally recommended, instead of aiding, actually 
interferes with the proper moulding of the head. If the pelvis is large 
enough to allow the child to be born without injury, the application of 



XXIX.] 



USB OF THE FORCEPS. 



489 



the blade behind the pubis can only interfere with adaptation and 
descent, while the presence of its fellow on the side of the cranium next 
to the sacrum prevents the head from doubling the promontory, by mak- 
ing it "a centre of revolution/ 7 like that of the symphysis in the later 
stages of labor. In place of the natural moulding, the head is violently 
compressed and dragged through the inlet without any regard to the 
measures which nature herself adopts to remedy the results of these 
errors of conformation. Forceps are therefore to be applied in relation 
to the pelvis and not to its contents. They are to be used as tractors, 
not compressors. The instruments of Simpson, which are now begin- 



FlG. 162. 




C D, curve of abnormal promontory ; B A, Carus's curve. Modified from Barnes. 



ning to be used in this country, have a space of three and one-quarter 
inches between the fenestra*. Such an instrument is almost useless as 
a compressor, but as a tractor it is efficient and powerful. In speaking 
of this subject at the discussion at the Obstetrical Society of Philadel- 
phia, in 1872, Dr. W. F. Jenks called attention to the fact that " the 
great advantage which results from the use of an instrument intended 
only to supplement a deficient vis a tergo, is that the mechanism of 
labor can, and does in most cases, when the contraction is not too great, 
proceed undisturbed, the head rotating anteriorly inside the blades. In 
these cases, where this rotation does not take place, we only imitate 
nature, for in cases of contracted pelvis, when the maternal efforts are 
finally sufficient to effect delivery, we find that this rotation of the head 
does not occur until late in the process of mechanism. 

"The fact of rotation of the head occurring within the blades cannot 
admit of any question. Any one who has used an instrument where 
powerful compression is not excited, has had repeated opportunities of 
verifying the fact. The testimony of Brown, Hohl, Scanzoni, Schroe- 
der, and others is full and decisive on this point. That this rotation 
does really take place, and that the operator is not deceived by having, 
in fact, applied the instruments primarily on the sides of the head, is 



490 THE FORCEPS. [CHAP. 

proved by the marks of the blades over the brow and behind the ear, 
the marks showing the application of the instrument on the fronto- 
mastoid diameter at the superior strait, where the want of relation be- 
tween the head and pelvis was sufficient to cause the close adaptation 
of the blades to the head, and their pressure into the soft tissues of the 
scalp, while the position of the blades on the sides of the head in its 
passage through the vulvar outlet leaves the fact of rotation beyond 
doubt" 

The great difficulty in these cases is when the head is driven down 
between the projecting promontory and the brim. Every one knows 
that it is often very difficult to seize it when it is free and movable at 
the superior strait. These difficulties are so great that many competent 
authorities practice version in preference to employing the forceps under 
these circumstances. If the head, transverse at the superior strait, is 
tightly compressed in the conjugate, it is much more troublesome to 
apply the forceps to its sides than when it is free at the brim, just as 
Hodge acknowledges that the blades are harder to get in place when 
the un rotated head is wedged in the cavity, than it is when it is more 
movable, but at the brim. Many assert that it is not possible to apply 
the forceps to the side of the head when it is transverse and nipped 
between the promontory and pubis. Indeed, this appears to be the 
opinion of most authorities. We will not say that it is impossible to 
do this, since accoucheurs of our acquaintance and of large experience 
state that they have done it. We do not hesitate, however, to condemn 
the practice as dangerous to the mother, without offering any additional 
advantages to the child, since it interferes with the natural mechanism 
of labor in contracted pelves. Dr. Jenks, in the discussion previously 
alluded to, in speaking of the application of the forceps under these 
circumstances, says that "in these cases the blades will grasp the head 
in spite of any efforts to the contrary, in the oblique or fronto-mastoid 
diameter ; in other words, they are applied to the sides of the pelvis, 
for this term 'sides of the pelvis' must not, as is often the case, be 
taken to represent mathematically the terminations of the transverse 
diameter, but the space between the ilio-pectineal eminence and the 
sacro-iliac synchondrosis. It would be well if the term 'sides of the 
pelvis' should be abandoned, and the relation of the instrument to the 
oblique diameter of the head substituted. The application of the in- 
strument in these cases is not then a matter of election, but of neces- 
sity."— P.] 

The patient may here also lie on her left side ; and there is this 
advantage in the double-curved forceps, that there is not the same 
necessity for bringing the hips over the edge of the bed, as from the 
nature of the pelvic curve the handle of the upper blade does not re- 
quire to be nearly so much depressed. The rules given for the intro- 
duction of the blades in these cases vary considerably. We prefer, as 
in the case of the ordinary forceps, to pass the lower blade first. Some 
operators, following the advice of Madame Lachapelle, will pass this 
blade along the sacro-sciatic ligament ; but the most experienced of 
modern authorities prefer to pass it over the perineum into the hollow 
of the sacrum, a little to the left of the middle line. If the former 



XXIX.] 



DELIVERY BY LONG FORCEPS, 



491 



method be practiced, the handle must be directed somewhat to the 
right, although much less so than in the case of the straight forceps. 
If, on the contrary, the operator should select, as we would recommend, 
the second process, the blade may be directed, as is here shown, pretty 
nearly in a horizontal position, into the hollow of the sacrum. That 
the introduction of the double-curved forceps is a more complicated 
proceeding than the operation previously described, no one will dispute; 
and this indeed will appear from the description of this stage of the 
process given by Dr. Barnes: u As the point of the blade," he says, 



Fig. 163. 




Introduction of long pelvic-curved forceps. 

" must describe a double or compound curve — a segment of a helix — 
in order to travel round the head-globe, and at the same time to ascend 
forwards in the direction of Carus's curve so as to reach the brim of the 
pelvis, the handle rises, goes backwards, and partly rotates on its axis. 
The handle is now carried backwards and downwards to complete the 
curve of the point around the head-globe, and into the left ilium. 
Slight pressure upon the handle ought to suffice. This will impart 
movement to the blade ; the right direction will be given by the rela- 
tion of the sacrum and head." Dr. Barnes further illustrates this by 
the following diagram (Fig. 164), which we have slightly modified. 

The actual introduction of the blade is by no means so difficult, nor 
is it a matter of such nicety as the above description would seem to 
imply. The mere raising of the handle, after the blade has been so far 
introduced, causes it to glide upwards, unless some obstacle should 
exist to impede its progress. When thus adjusted to the side of the 
head, the weight of the handle will tend to keep it in position, but 
this will be more certainly effected by intrusting it to an assistant, who 
should hold it back towards the periueum to facilitate the introduction 
of the upper blade. As in the case of the other, this blade may also be 
passed in the direction of the hollow of the sacrum, and is carried in 
front of the lower blade, to the right of the middle line. The handle 



492 



THE FORCEPS. 



[CHAP, 



being now depressed and carried backwards, its movement directs the 
blade along the convexity of the child's head towards the right ilium ; 
and, when the movement is complete, the handles should be in apposi- 
tion and lock easily. Success in this will, however, depend upon the 
extent and nature of the distortion ; but, if the lateral walls of the 
pelvis are normal as regards their various planes, no great difficulty, 



Fig. 164. 




Diagram, showing various stages in the introduction of the long forceps (lower blade). 

after a little practice, will be experienced in the introduction and 
adjustment of the blades. The facility with which the lock is adjusted 
may be looked upon, not only as evidence that the blades are in contact 
with opposed surfaces of the head, but also that the case is one in which 
we may hope for a favorable result. But if, on the contrary, we do 
not succeed in introducing and locking the blades after one or two 
attempts carefully conducted, we must abandon the case as one unsuita- 
ble for the operation. 

[In this country the forceps are generally applied with the woman 
on her back. For this purpose she is to be brought to the side of the 
bed, and if the head is high up in the cavity, or at the brim of the 
pelvis, the buttocks must be well over the edge. The feet may rest on 



XXIX.] 



DORSAL POSITION. 



493 



two chairs, or they may be supported by assistants. The position is 
about that in which the patient is placed for the performance of the 
operation of lithotomy. 

It has been urged by those who apply the forceps with the woman 
on her side, that changing her position unnecessarily disturbs the pa- 
tient, and that the exertion which she has to make excites and alarms 
her. These objections have but little force. On the other hand, it 
may be urged that the accoucheur can appreciate the relations of the 
head and pelvis more readily when the woman is in the dorsal position. 
He can manipulate more easily both in introducing the blades ; and in 
the last stage of the delivery of the head, when it is necessary to carry 
the handles of the instrument well up towards the mother's abdomen. 

The mode of introducing the blades when the woman occupies the 
dorsal position does not differ in principle from the same manipulation 
when the patient is on her side. It is to be remembered, however, 
that in this country the long double-curved forceps are generally em- 
ployed, no matter what may be the situation of the head. In order to 
understand the movements which are necessary to effect the introduc- 
tion of the instrument, the student should remember that the problem 
is purely mechanical in its nature. He is called upon to grasp an oval 
body in a curved canal with an instrument which has two curves, one 
corresponding to the body to be seized, and the other to the passage in 



Fig. 165. 




Introduction of the first blade in the dorsal position. 



which it lies. In consequence of this he has to- execute two move- 
ments at the same time. Whatever may be the stage of labor at which 
arrest occurs, the operator, having prepared his instrument, introduces 
that blade of the forceps first which will be next the posterior commis- 
sure of the vulva, when the two blades are applied and locked (Clarke). 
It is always the blade which goes to the left side of the pelvis that oc- 
cupies this position. It is to be lightly seized with the left hand, the 



494 



THE FORCEPS. 



[CHAP. 



handle being elevated and carried to the right groin until the extremity 
of the blade is parallel with the lips of the vulva. The fingers of the 
right hand having been inserted into the vagina, the blade is now 
passed along these as a guide by gently depressing the handle, and at 
the same time carrying it inwards or towards the median line of the 
mother. The instrument is therefore introduced by a compound move- 
ment downwards and inwards, which leaves the lock projecting almost 
directly upwards, or a little towards the left side. The blade may 
now be supported by an assistant, or not, as may be necessary. The 
opposite branch is now seized in the right hand, while the fingers of 
the left are passed into the vagina to act as a guide. The handle is to 
be elevated and carried towards the left groin, until the extremity of 



Fig. 166. 




Introduction of the second blade in the dorsal position. 

the blade becomes parallel with the vulvar orifice, when the introduc- 
tion commences. 

The handle is now depressed, and at the same time carried towards 
the right side, or the median line. This compound movement elevates 
the blade in the pelvis, and at the same time carries it around the foetal 
head, so that the handle of the right branch is brought parallel with 
its fellow, and the articular surfaces are opposed to each other, and 
locking is readily effected. 

If the articulating surfaces of the lock are not directly opposed to 
each other, the handles should be carried well back towards the peri- 
neum, when the difficulty in locking is often overcome at once. 

If this does not follow, it may be proper to pass the fingers of one 
hand into the vagina, and by careful pressure upon one or the other 
margin of the blade, as indicated, aided by gentle manipulations of the 
handles, to so alter the position of the blades that locking can be 
effected. If this is not accomplished without the exertion of much 
force, the instrument should be removed and reapplied. 



XXIX.] LONG FORCEPS. 495 

Many American obstetric authors and teachers who assert that the 
forceps should always be applied to the sides of the child's head, give 
special rules for the introduction of the instrument in each position of 
the head. As in this work it is recommended that the blades be intro- 

Fig. 167. 




Instruments introduced and locked in the dorsal position. 

duced in relation to the sides of the pelvis, the student is referred to 
the writings of those who advocate opposite opinions for a description 
of the various and complex manipulations by which the blades are 
brought into relation with the sides of the head. — P.] 

It is assumed by many writers that the blades, when introduced, 
correspond to the antero-posterior diameter of the head. It is not so, 
however. The head, indeed, very generally occupies the transverse 
diameter of the pelvis, but the tendency of the blades is to adapt them- 
selves to one or other oblique diameter, as has been showm by Simpson. 
This has been conclusively established by examination of the head, 
after delivery by this process, when it is found that one blade has 
passed behind the ear, and the other has reached over the frontal bone 
on the opposite side, and has been applied over or in the immediate 
neighborhood of the orbit, as is shown in Fig. 168. 

The forceps being thus applied, the next step in the process is an 
attempt at extraction. Remembering the power which we possess in 
so formidable an instrument as this, we must, in the first place, exer- 
cise great caution in the matter of compression ; and this point is all 
the more necessary as the handles will be found to gape more than is 
usual, owing to the length of the cranial diameter which is between 
the blades. Moderate compression is all that is necessary to maintain 
the position of the forceps when well applied, for we know T that it is 
not by manual compression only, but also by compression of the blades 
by the walls of the natural passage, that their grasp is sustained. The 
handles are to be seized by both hands and steady traction practiced, 
the direction at first being somewhat backwards. As in the case of the 
ordinary forceps, the traction must not be continuous, but in aid of 
present, or in imitation of absent pains ; and, at the same time, we 



496 



THE FORCEPS, 



[CHAP. 



combine with mere pulling effort a moderate degree of the swaying or 
double-lever action, taking great care not to injure the perineum. 



Fig. 168. 




Long forceps applied. 

The thorough control which the size of the handles gives us over the 
instrument enables us to perceive with greater accuracy whether or not 
the head can be dislodged by such efforts as we are justified in making. 
This may be more exactly ascertained by passing the finger from time 
to time in the direction of the head, when the descent of the occiput or 
the rotation of the sagittal suture towards the conjugate diameter may 
afford clear evidence that the head is making progress. As it descends, 
the handles of the forceps will be observed to rotate, and in some cases 
it may be possible to assist the rotation. When this stage has been 
reached, it will be proper to carry the handles more forwards, and to 
pull rather downwards than backwards, following the curved axis of 
the pelvic cavity. Finally, the operator must carry the handles for- 
wards and upwards in front of the symphysis; and, in order that this 
may be effected with ease, the right thigh should be raised by the 
nurse, or the patient may be laid on her back so as to permit the 
handles to move upwards in the direction of the umbilicus. The 
operator must, however, beware of moving the handles prematurely 
in this direction, as he may thereby do mischief. And there is another 
danger which he must specially avoid, viz., the ploughing up of the 
perineum by the blade, which, in consequence of the rotation, is now 
turned against it. This may, no doubt, be avoided by disarticulation 
of the blades as the head approaches the outlet; but, as it is often 
necessary to continue the traction to the last, extreme caution must at 
this stage be observed. In nothing should we be more particular, than 
in the slowness and deliberation with which we conduct the various 
stages of this operation ; for, in all the details, the more closely we are 



XXIX.] APPLICATION TO FACE AND BREECH CASES. 497 

enabled to imitate nature, the more likely is the operation to have a 
successful result. 

It may be necessary to apply the forceps in the treatment of pres- 
entation of the face. So long as the chin is turned forwards, as it is 
in what we have described as the third and fourth varieties, the case 
is in all respects a normal one, and should be left to nature. But 
inertia, and the other causes which call for the forceps in a cranial 
position, may, in such a case, exist also, demanding instrumental 
assistance. The application of the forceps is here in no respect more 
difficult, nor more serious, than when the vault of the cranium is the 
presenting part, the chin being regarded throughout as strictly anal- 
ogous to the occiput in the mechanism and direction of its birth. The 
rules, therefore, which have been laid down for the application of the 
forceps in occipitoanterior positions of the vertex, may here be adopted, 
mutatis mutandis, with equal propriety. It is very different when we 
have to deal with a mento-posterior position of the face, which is by 
far the most unfavorable of all possible presentations of the cephalic 
extremity. Such is, as we have seen, the probable position of the 
majority of face cases at the beginning of labor, rotation of the chin 
forwards occurring as the head descends. 

But the cases to which we refer are when this rotation fails, and 
when the head descends into the cavity in its original position with 
reference to the pelvis. Two methods of treatment have here been 
suggested, and have apparently been practiced with success ; these 
being application of extracting force over the occiput, so as to convert 
it into an ordinary cranial position, and rotation by twisting the blades. 
Smellie, Cazeaux, and others, have succeeded by the first method : but 
that which seems most practicable, at least from a theoretical point of 
view, is rotation, a manoeuvre which, for obvious reasons, can only be 
practiced with the straight forceps. By the latter means, rectification 
has in many instances been effected, so as to insure a favorable termi- 
nation of the labor ; and it would be proper in every such case to make 
the attempt; but, if we fail, and the symptoms indicate approaching 
exhaustion, or are otherwise such as are held to imply a necessity for 
speedy delivery, we may have no resource remaining but craniotomy. 
If, in a deformed pelvis, the face presents at the brim, turning is better 
than the long forceps in most cases ; and if the chin is backwards, there 
can be no doubt about it. 

In all cases of pelvic presentation, and in the last stage of delivery 
by podalic version, we have the forceps ready, lest any difficulty should 
arise in regard to the extraction of the head by the ordinary process. 
The chin, in such cases, being almost always turned backwards towards 
the perineum, the blades are passed in front of the sternum of the child 
over the chin and sides of the head. The body of the child is then to 
be carried upwards, towards the abdomen of the mother, by an assistant, 
when, if the handles of the forceps are made to follow it in the same 
direction, combining the movement with a moderate amount of traction, 
the head will usually be extracted without difficulty. This is an opera- 
tion in which delivery must often be effected with greater precipitancy 

32 



498 



THE FORCEPS. 



[CHAP. 



than usual — as, for example, when twitching of the limbs shows that 
asphyxia is impending. There are other comparatively rare instances, 
in which the operation is not effected with such ease. We may encounter 
cases, for example, in which, the trunk being born, the face has not 
rotated backwards. These are the instances in which Madame Lacha- 
pelle advises us to rotate the face by the finger before extracting it ; 
but, if this cannot easily be done, it will be better to adopt the plan 
suggested by Velpeau, and endeavor to drag down the occiput beyond 
the edge of the perineum, and deliver the head by a movement of ex- 
tension, instead of, as is usual, by the ordinary one of flexion. There 
are cases, also, in which the head, after turning or in breech presenta- 
tion, is arrested at the brim in consequence of deformity, when it might 
be possible to deliver by applying the forceps along the sides of the 
pelvis ; and there are instances, rarer still, in which the head is sepa- 
rated, and left behind in the cavity of the uterus, where we must attempt 
extraction by the forceps, so adjusting the blades as to prevent the pos- 
sibility of the occipito-mental diameter being thrown across the pelvis. 
The difficulties which, under special circumstances, attend the intro- 
duction of the forceps have given rise to innumerable modifications of 



Fig. 109. 



Fig. 170. 





Ziegler's forceps. 



Radford's forceps. 



the instrument, none of them (with a few exceptions, such as the forceps 
of Mondotte, in which the blades do not cross) affecting the general 
principles upon which the instrument is constructed. To one or two 



XXIX.] VARIETIES. 499 

only of the more important of these we may call attention. Dr. Ziegler, 
of Edinburgh, has recommended a forceps of which the blades are 
straight, but dissimilar. The fenestra of one blade is carried down to 
the handle, and in introducing the instrument, the elongated fenestra 
is slipped over the handle of the other blade, which has been previously 
passed, and which serves, therefore, as a guide for the adjustment of 
the other. What is described in the Obstetrical Society' 's Catalogue as 
Mr. Philip Harper's forceps seems, both in principle and construction, 
to be identical with Dr. Ziegler's. 

Dr. Radford, again, has invented an instrument, of which the blades 
are of unequal length, and in which there is a reversed position of the 
lock. This ranks as a long straight forceps, and is designed by the 
inventor for application to the head when it is arrested at the brim, 
the long blade being passed over the face, and the short one over the 
occiput. The opening formed by the curve in the shank of each blade 
is for the purpose of passing a handkerchief through, and will enable 
the practitioner, in addition to his hold of the handles, to use very 
powerful and effective extracting force. To these we might add 
numerous varieties, which exhibit infinite peculiarities, and which differ 
from the familiar standards in the nature of the curves, pelvic or cranial, 
the length of the fenestra?, the width of the blades, and the arrange- 
ment of the shanks, handles, and locks. To describe even a tithe of 
these would carry us beyond our prescribed limits, and would serve 
no useful purpose. 

In expressing a preference for the straight over the double-curved 
forceps, in all ordinary cases, we must not be supposed dogmatically to 
condemn the latter instrument in what are generally called short forceps 
operations, or, indeed, in any other, save those in which we use the 
forceps for the purpose of effecting rotation. The authority of those 
who have pronounced more or less emphatically in its favor is of too 
great weight to be overlooked. We are inclined, more particularly, 
to admit the force of Simpson's observation, that it is well for the 
operator to accustom himself to the use of one kind of instrument only, 
as a strong argument in favor of the pelvic curve; but, on the other 
hand, we entertain personally so strong a conviction that the straight 
forceps, while it can effect, below the upper third of the pelvic cavity, 
everything which the other can achieve, is essentially easier of applica- 
tion by beginners, as it is, undoubtedly, simpler in construction than 
its rival. When once its special difficulties are overcome, we cannot 
doubt, however, that in hands familiar to its use, the double-curved 
forceps fulfils all the indications of a safe and efficient extractor. 

We would conclude this chapter with a single word of caution to the 
young practitioner who has overcome the preliminary difficulties, and 
w T ho has attained a certain amount of confidence and skill in the use of 
the instrument. It is to beware lest this should lead him to a too fre- 
quent and unnecessary application of it. Above all, let him remember, 
that no mere question of time, or of his own convenience, can ever be a 
sufficient warrant for operative interference. No operation is without 
risk, and nothing, therefore, short of a conscientious conviction that he 



500 . THE VECTIS. [CHAP. 

is about to act in the interests of the mother or the child, can ever 
absolve him from the responsibility which attaches to him in virtue of 
the position which he occupies. 



CHAPTER XXX. 

THE YECTIS ; FILLET ; BLUNT HOOK, ETC. ; DECAPITATION. 

DISCOVERY OF THE VECTIS BY ROONHUYSEN — MODE OF USING THE VECTIS — CASKS 
TO WHICH IT MAY BE APPLIED — THE FILLET; A CONTRIVANCE OF ANCIENT 
ORIGIN ; APPLICABLE CHIEFLY TO BREECH CASES — THE BLUNT HOOK — THE 
CROTCHET; PRECAUTIONS NECESSARY IN THE USE OF THE CROTCHET: THE 
GUARDED CROTCHET — USE OF TWO CROTCHETS — DECAPITATION: VARIOUS IN- 
STRUMENTS FOR: DESCRIPTION OF THE OPERATION: EXTRACTION OF THE 
TRUNK : SUBSEQUENT EXTRACTION OF THE HEAD BY THE VARIOUS METHODS 
OF THE FORCEPS, CROTCHET, OR CEPH ALOTRIBE. 

About the same time that the discovery of the Chamberlens was 
gradually brought to light and introduced into practice in this country, 
the Vectis or Lever was being used for the delivery of women in Hol- 
land by Roonhuysen. The frequent sacrifice of infant life — which was 
rendered necessary in cases of difficult or obstructed labor — was no 
doubt the cause which, in both cases, turned the attention of the in- 
ventors to the subject, with the earnest desire to devise any means 
whereby the crotchet and perforator might be superseded by some con- 
trivance which would deliver the woman without destroying her child. 
The discovery of Roonhuysen, although of much less importance than 
that of Chamberlen, was an inestimable advantage in practice; and, by 
the rude instrument contrived by the Dutch accoucheur, many success- 
ful operations were performed by himself, his son, Ruysch, and some 
others to whom the secret had been communicated. This original lever 
was of the simplest possible construction, and consisted of a flat piece 
of iron, bent at each end into a slight curve, and covered with soft 
leather to protect the external parts. The secret of the lever was even- 
tually purchased from those to whom it had been handed down after 
Roonhuysen's death, by two Dutch physicians, Visscher and Van den 
Poll, whose names are more worthy of being recorded than those of 
the inventors, as they jointly paid the sum of 5000 livres in order that 
they might impart to the world a secret which should never have been 
withheld. As the knowledge spread, the simple contrivance of the 
originators became altered and modified, until it resulted in the vectis 
of the present day. 

One is apt to suppose, that, as the Vectis is now seldom used, it has 
been discarded as a worthless instrument. So far, however, from this 
being the case, the vectis must always be looked upon as an extractor 
of considerable power and efficiency, and the sole reason for the neg- 
lect into which it has now fallen, is simply because it has been utterly 



XXX.] 



THE VECTIS. 



501 



Fig. 171. 



thrown into the shade by the forceps. There are, moreover, even in 
the present day, practitioners of great experience who occasionally use 
the vectis in certain cases in preference to the more familiar instrument. 
The modern vectis has, in its general appearance, a certain resemblance 
to a single blade of the short forceps, and like the latter, varies greatly 
in its shape, handle, and fenestra ; but more particu- 
larly in the curve which is given to it with a view to 
efficient adaptation to the head of the child. The 
variety which is here represented is one of the best 
known of the numerous modifications of Roonhuysen's 
lever. It is sometimes furnished with a hinge be- 
tween the handle and the blade, — a principle which 
has also been applied by some to the forceps, with the 
view of facilitating the introduction of the upper 
blade. Such an arrangement is, however, quite un- 
necessary, if the woman is placed in the proper posi- 
tion on her left side, and her hips are brought quite 
over the edge of the bed, when it may be introduced 
without difficulty with reference to any position of the 
head, or any part of the circumference of the pelvic 
wall. 

If we had not at our command a safer and more 
perfect agent in the forceps, there can be no doubt that 
the vectis would be an instrument of every-day use 
for the extraction of the child, whether employed as a 
lever or a tractor. These two ideas have, manifestly, 
been the guiding principles upon which suggestions as 
to the modification of the instrument have been based ; 
when the idea of leverage has predominated, the curve 
has been slight ; whereas, when traction has been the 
object, the curve has been greater, so as to secure, for 
this purpose, a firmer hold of the head. No efficient action of the vectis 
can, however, be produced, unless the principle of a simple lever is 
more or less brought into play; for, even if we admit it as possible that 
it may act as a tractor, it can obviously act only upon the end of a 
cranial diameter, which latter becomes a lever, the fulcrum of which is 
at the other pole of the diameter thus acted upon. But its efficient 
action is scarcely compatible with this idea, as it will generally be 
found necessary so to use it as to make the blade itself a lever, the ful- 
crum of which must be found in some part of the pelvic wall. This, 
in fact, is the great objection to the vectis, when we compare it with 
the forceps, where the fulcrum of each blade is the lock. It may no 
doubt be possible, in the case of the single lever, to protect the soft 
parts by interposing a finger where the force is brought to bear upon 
the fulcrum, and we may be sure that this is the manner in which 
Roonhuysen and his followers operated ; but still, even under the most 
favorable circumstances, the danger which arises from such a plan of 
action must be viewed as considerable, and in direct proportion to the 
mechanical force employed. 

When the vectis is used with the view of facilitating delivery in 



The vectis. 



502 THE VECTIS. [CHAP. 

cases of cranial presentation, it is essential, in the first place, that the 
position of the head be accurately ascertained ; and, further, that the 
operation should be conducted with a perfect knowledge and apprecia- 
tion of the laws upon which the natural phenomena of parturition de- 
pend : the object being chiefly, therefore, to bring the occiput forwards 
under the arch of the pubis. If we should thus succeed, by pulling 
down the occiput, in increasing the occipitofrontal obliquity of the 
head, it is clear that we are, at the same time, closely imitating the 
process by which nature manages the descent of the head. This may, 
if the uterus is acting efficiently, be all that is required ; and, in any 
case, it advances matters a stage. But, in cases of unusual difficulty 
or absolute inertia, little ultimate good will result if we stop short at 
this stage of the operation, so that we can only act effectively by bring- 
ing our force to bear against the two ends alternately of the occipito- 
frontal diameter. So soon, therefore, as we have succeeded in causing 
the occiput to advance, the vectis is to be withdrawn and adjusted to 
the frontal pole; and by thus acting, now on the occiput and again on 
the forehead, we may certainly and steadily cause the head to advance 
in the direction of the outlet. A blade which is sharply curved will, 
no doubt, take a firmer hold of the part to which it is applied, but 
this advantage is probably more than counterbalanced by an increased 
difficulty in its introduction. It is for this reason that a more gentle 
or wider curve has been generally preferred, which, while permitting 
of easier introduction, makes it more necessary that the blade itself 
should be used as a lever; and, indeed, some have gone so far as to 
say that no vectis can possibly be better than a single blade of the 
straight forceps. 

It would appear that the cases in which the modern accoucheur may 
with advantage have recourse to the vectis, are those in which his 
primary object is to act upon the occipitofrontal diameter of the head. 
Should it seem, therefore, that all that is necessary is to insure the 
descent of the occiput, it is possible that delivery may thus be effected 
with even more safety than by the forceps, where the action bears upon 
the poles of the transverse diameter. Contingencies may also arise, in 
the course of many operations in midwifery, in which the operator 
might avail himself of the vectis if it were at hand ; but it is probable 
that in no instance is the vectis more applicable than when we wish to 
correct malposition of the vertex. The natural process, by which 
occipito-posterior positions of the vertex terminate by rotation, has 
already been fully described ; and it has also been observed that an 
essential condition to such rotation is the descent of the occiput, along 
the posterior pelvic wall, while the forehead remains high in the direc- 
tion of that cotyloid cavity to which it is turned. In proportion, there- 
fore, as the forehead descends {fr onto- cotyloid position of West) along 
the anterior wall, the more do we despair of natural rotation, and look 
with apprehension to the probability of a tedious labor, or a birth with 
the forehead to the pubis. Much may, as we have shown, be done by 
the fingers of the operator directed against the frontal end of the occipito- 
frontal diameter; and, indeed, while propulsive effort exists, nothing 
is so likely as this to encourage descent of the occiput. But when this 



XXX.] 



THE FILLET. 



503 



procedure fails, we have in the vectis a powerful auxiliary, which we 
may pass over the occiput ; and, thus, by pulling the occiput down 
and pressing the forehead up, we act simultaneously upon the two poles 
of the long diameter, in restoring or maintaining that position of the 
head in which alone nature effects rotation. We may even conceive it 
possible, that, by a similar mode of procedure, we might convert by 
this instrument a face presentation into one of the vertex, by producing 
a rotation of the head on its transverse axis. We assume, then, that 
with rare exceptions, the vectis, although a powerful instrument, is 
completely superseded by the forceps; by which can be effected more 
speedily and more safely, almost all that the vectis can accomplish. 

The Fillet (laqueus) is probably the most ancient of all the instru- 
ments used in obstetrics with the view of extracting a living child. In 
its simplest form, it is nothing more than a loop or noose, which may 
be variously adjusted so as to facilitate the delivery of the child. It 
has been constructed, according to Ramsbotham, " of a strip of strong 
cloth, silk, or leather, formed into, a running noose, and was sometimes 
sewn up like an eel-skin, open at both ends, to admit the introduction 
of a piece of whalebone, cane, or wire, throughout its entire length, by 
which its application might be facilitated. It was intended to be in- 
troduced over the head in whatever way was most easily accomplished ; 
and, this done, the cane was to be withdrawn, the loop tightened, and 
extraction was to be effected by main force." Such an instrument is, 
in as far as cranial presentations are concerned, so manifestly inferior to 
the forceps, that we can scarcely wonder that it has 
so completely fallen into disuse as not even to be 
mentioned in many of the best works on obstetrics. 
Some modern authorities have, however, so far, ap- 
proved of the principle upon which it is constructed, 
as to direct their ingenuity to the manufacture of a 
more perfect instrument, of which the " whalebone 
fillet" here shown is the most familiar illustration. 
Its length is about ten inches, the loop being seven 
inches and a half, and its extreme width three inches 
and a half. In its application, the loop is to be 
passed over the occiput, and steady traction exer- 
cised, when, if this is not sufficient, it may be 
adjusted over the forehead or chin, thus alternating 
the extracting force between the frontal and occipital 
poles of the long diameter of the head, in a manner 
somewhat similar to what is practiced in the case of 
the vectis. 

The fillet may still be usefully employed in the 
management of breech presentations, when delivery 
is arrested either by inertia or disproportion of the 
parts. Some have, under such circumstances, in- 
sisted that the forceps may be used ; but the expe- 
rience of the great majority of practitioners has shown that we cannot 
depend upon that instrument, which is essentially constructed for 
application to the cranium. A most efficient means of extraction is, 



Fig. 172. 




Whalebone fillet. 



504 



THE BLUNT HOOK, 



[CHAP. 



Fig. 173. 



no doubt, afforded here by the blunt hook, but the objection to that 
instrument, as has already been stated, is the injury which may, by its 
use, be inflicted upon the groin and genital organs of the child. The 
fillet may, however, be substituted, and employed both with safety and 
efficiency. A simple loop or noose, as was the nature of the original 
fillet, is, in such instances, to be passed over the flexure of the thighs, 
by means of the fingers, an elastic catheter, or (as has been suggested) 
the instrument which was designed by Belocq for plugging the poste- 
rior nares. Nothing serves the purpose better than a simple skein of 
worsted, one end of which is introduced in this way, and the other 
extremity then passed through it so as to form a running noose. This 
noose may, again, be adjusted so as to direct the extracting force in the 
proper manner; and, as our object generally will be to pull down that 
hip which is turned forwards in the pelvis, in advance of the other, 
the noose should therefore be placed nearly over the anterior ischial 
tuberosity. 

The Blunt Hook, which is here shown, is also an instrument of 
ancient date. It has been recommended in cases of obstructed breech 
delivery ; but the danger of wounding the soft parts of the child w T hich 
it entails, is now very properly held to be such a serious 
objection to its use, that it has been entirely discarded 
in cases where there remains a possibility of the child 
being alive. In all cases in which the child is ascer- 
tained to be dead, the blunt hook may be used without 
hesitation ; and, in these cases, it is a powerful auxil- 
iary to many of the more important operations of mid- 
wifery. It is, however, less an instrument adapted to 
any special operation, or operations, than one which 
may be useful in a hundred different ways, while we 
are attempting to extract the child in cases of unusual 
difficulty. It acts most powerfully when hooked into 
the flexure of a joint. In this way, as we have seen, 
powerful extracting force may be brought to bear, 
when the breech presents, by passing it over the groin; 
and, in like manner, in cephalic presentations, the 
shoulder may be made to advance by tractile effort of 
a similar kind brought to bear upon the axilla. But 
while these are, perhaps, the circumstances under which 
the blunt hook is most frequently and usefully em- 
ployed, it gives no idea of the real scope of the instru- 
ment. This, indeed, embraces points in the detail of 
many of the chief operations of midwifery ; and, in the 
forcible extraction of the child, after the performance of 
craniotomy or embryulcia, the hook is almost indispen- 
sable. Its advantage, as compared with the crotchet, is that, as there 
is no necessary laceration attendant upon its employment, it is not ab- 
solutely unsuitable for the delivery of a living child ; and, besides, 
that being blunt, there is not, should it chance to slip, the same risk 
to the maternal parts. 

The Crotchet was described by Hippocrates, more fully by iEtius, 



The blunt hook. 



XXX.] 



THE CROTCHET. 



505 



Fig. 174. 



and is alluded to more or less distinctly by all the ancient writers on 
midwifery. It is, like the instrument just described, a hook; but it 
differs essentially in this, that it is always sharpened, so as to pierce 
the tissues, and thus secure a better hold. In its nature, then, the 
crotchet is an appliance which can never be used when we have any 
hope, however remote, of saving the life of the child. The introduc- 
tion and fixing of the instrument is a matter of little or no difficulty, 
nor is it attended with any danger to speak of, as the sharpened por- 
tion, being the point of the hook, is turned downwards. But, so soon 
as the direction is reversed, and we attempt extraction, the crotchet 
becomes, in careless and inexperienced hands, a highly dangerous im- 
plement. In all cases, therefore, in which a sufficient hold can be had, 
we will, as a matter of course, prefer the blunt hook ; but, 
when it is necessary to act upon flat surfaces, the blunt 
hook is worthless, and we are obliged to have recourse to 
an instrument which may penetrate, and thus be fixed 
upon any surface to which it is applied. The nature of 
the crotchet renders, however, the maintenance of its grip 
upon soft tissues extremely precarious, and any violent 
effort at extraction can scarcely fail to cause extensive 
laceration, which, in its turn, permits of the sudden de- 
tachment of the instrument from the point at which it 
has been fixed. Every practical accoucheur knows that 
no confidence whatever can be placed in the instrument 
as a tractor, unless we can fix it in some unyielding part 
of the bony structures, upon which alone- we can safely 
bring anything like efficient effort to bear. 

But, even this is far from safe ; for, under the influence 
of powerful effort, the crotchet may at any moment, even 
when it is apparently well fixed, break suddenly from its 
attachment. This is, in fact, the special danger of the 
crotchet and the great objection to its use, as by such an 
accident the maternal structures may, in a moment, be 
seriously, or even fatally injured. It is on this account 
that no sound practitioner will ever use the crotchet, with- 
out taking great pains to guard against the result which 
may possibly ensue ; and he therefore invariably uses the 
finger of one hand as a guard to the crotchet, so that, if it should slip, 
the maternal parts are efficiently protected. An instrument called the 
" guarded" crotchet, in which a spoon-shaped blade is substituted for 
the fingers, as a guard, is, as we shall find (see Fig. 183), occasionally 
used at a certain stage of the operation of craniotomy. 

While we thus admit the full force of the objections which exist to 
the use of the crotchet, it must be confessed that, in cases of great diffi- 
culty, it is a valuable, and almost indispensable aid. The point of 
greatest importance is to secure for it a firm and unyielding attach- 
ment, so that it is usual to try to fix it in the orbit or mouth, or else- 
where in the same region, so as to maintain an efficient hold upon the 
irregular bones of the face ; and, in those instances in which it is passed 
within the cranium, or any of the other hollow cavities of the body, 



The crotchet. 



506 DECAPITATION. [CHAP. 

the same principle guides our action, so that we may find ourselves at 
one time fixing it in the foramen magnum, and at another attaching it 
to the spinal column, or the pelvic brim. 

The nature of the crotchet is such that it can operate upon one point 
only of the circumference of the head, or other presenting part. If we 
act, therefore, in a cranial presentation, in this manner upon the orbit, 
we run the risk of dragging down the forehead by a movement of the 
head on its transverse axis, without securing any actual advantage, and 
with the possibility, if the chin be backwards, of making matters worse. 
xEtius, in one of the most interesting passages of his obstetric works, 
recommends that we should operate by two crotchets, applied at the 
sides of the pelvis, to opposite surfaces of the child's head, and then 
pull downwards, in order that the traction may be equal, and in the 
direction of the resultant of the two forces (ad neutr am partem dcclinans). 
Had he but thought of the possibility of applying the same principle 
to the delivery of the living child, he would almost inevitably have 
discovered the forceps. But, as in the case of Hippocrates and the 
olive, such speculations are perhaps more interesting than instructive. 
The hint here given, as to the combined action of two crotchets, is not 
to be despised, as there are certainly cases in practice in which the 
principle indicated might usefully be adopted ; and this, in fact, was 
recommended and practiced by Dr. Davis. In so far as cranial pres- 
entations are concerned in which the forceps fails, or in which the use 
of that instrument is contraindieated, no good can possibly result, 
except under peculiar or exceptional circumstances, from the use of the 
crotchet, until we have already diminished the head by perforation of 
the cranium, and extraction of its contents. 

Decapitation. — An instrument closely resembling, in shape and gen- 
eral appearance, the blunt hook, but which is usually sharp within the 
curve, has been used with success in the treatment of those difficult 
cases of transverse presentation in which the ordinary methods of 
treatment have failed. This operation simply consists in abridging 
the long diameter of the child by a section made at the neck. It is 
described by Celsus, and by many writers subsequently ; but, with the 
exception of Davis, Ramsbotham, and, more recently, Barnes, the sub- 
ject has not received that attention in this country which it seems ob- 
viously to merit. It seems to us advisable, therefore, that we should 
in this place describe the operation somewhat in detail. This mode of 
procedure is chiefly applicable to those instances in which we have to 
deal, either with a neglected case of shoulder presentation, where the 
body of the child is partly impacted, or is so tightly embraced by the 
uterus as to render turning impracticable; or with a case in which the 
difficulty arises mainly from pelvic distortion, complicated with a trans- 
verse position of the child. 

The form of hook already described is that which is best known in 
this country, and is commonly called Ramsbotham's hook; but a num- 
ber of other instruments, more or less resembling this, as well as some 
of a different construction, have been recommended. Among the latter 
may be mentioned a contrivance which consists of a strong cord, which 
is to be passed round the neck, and then, by a saw motion, is carried 



XXX.] REMOVAL OF THE HEAD. 507 

to and fro by means of cross handles at its extremities, until the head 
is severed. It is probable that a modification of the wire rope ecraseur 
might be advantageously used for the same purpose, but the difficulty 
in such cases would probably be the passing of the rope around the 
neck. It w r ould appear that, with the ordinary instrument, a cutting 
surface is by no means absolutely essential, as some have succeeded by 
means of the ordinary blunt hook. The operation of decapitation by 
Ramsbotham's hook or Braun's " decollator," is well described by Dr. 
Barnes as consisting of three stages. The first stage is the application 
of the decapitator and the bisection of the neck ; the second is the 
extraction of the trunk ; the third, the extraction of the head. 

The first point to be accurately ascertained is the position of the 
body of the child, whether dorso-anterior or dorso-posterior. This 
being determined, in the manner already described, by an observation 
of the prolapsed hand, and the woman being placed in the ordinary 
obstetric position, or on her back, the arm is to be firmly pulled down- 
wards, so as to bring the neck, as far as is practicable, within the reach 
of the operator, and is then to be intrusted to an assistant, whose duty 
it is to maintain the position by steady and moderate traction. The 
bladder — and, if it be necessary, the rectum — are now to be emptied 
of their contents, and the hands and hook smeared with lard or oil. 
The fingers of one hand — right or left, according to the position — are 
then gradually insinuated in a direction corresponding to the anterior 
surface of the child, so as to reach the front of the neck. With the 
other hand the operator then introduces the hook, " laying flat," says 
Barnes, "between the wall of the vagina and pelvis and the child's 
back, until the beak has advanced far enough to be turned over the 
neck. The beak w r ill be received, guided, and adjusted by the fingers 
of the left (opposite) hand. The instrument being in situ, whilst 
cutting or breaking through the neck, it is still desirable to keep up 
traction on the prolapsed arm. In using Ramsbotham's hook, a saw- 
ing motion must be executed, carefully regulating your action by aid 
of the fingers applied to the beak. If Braun's decollator be used, the 
movement employed is rotary, from right to left, and at the same time, 
of course, tractile. The instrument crushes or breaks through the ver- 
tebra?. When the vertebrae are cut through, some shreds of soft parts 
may remain. These may be divided by scissors, or be left to be torn 
in the second stage of the operation — the extraction of the trunk." 

The delivery of the trunk and limbs of the child is now to be 
effected, mainly by pulling upon the arm ; but, should the force requi- 
site be considerable, it will be proper to pass the blunt hook into 
the axilla of the opposite side, in order to economize the tractile force 
on the depending arm. Care must, however, be taken not to use the 
hook with too great force, as by causing the premature descent of the 
upper shoulder we would throw the great diameter of the shoulders 
across the pelvis, and thus, it may be, render the extraction of the 
trunk a matter of increased difficulty. Generally speaking, no great 
difficulty, in the absence of pelvic deformity, will be encountered in 
this stage of the operation ; and steady traction will cause the shoulders, 
trunk, and breech, successively to pass along the pelvic canal. The 



508 DECAPITATION. [CHAP. 

head, if completely separated, will move to the side, and will be no 
obstacle to the passage of the body. 

The extraction of the head of the child, which constitutes the third 
stage of the procedure, is by no means an easy operation, and is some- 
times, in fact, the most difficult point of all. A good deal will depend 
upon the condition of the uterus as regards contraction. During the 
second stage, it will be the duty of an assistant to keep up steady 
pressure upon the fundus of the uterus, and to follow it downwards 
as the trunk is being gradually expelled, so as to encourage, as tar as 
may be possible, efficient and symmetrical uterine contraction, under 
the influence of which the head will be grasped, forced down in the 
direction of the cavity, and maintained in a comparatively fixed position. 
Another condition likely to exercise an important influence is the state 
of the head itself, which, if decomposition has advanced, will be easily 
compressible, the flat bones being so loosely connected with each other 
as to admit of overlapping to a very unusual extent. Various methods 
have been suggested and practiced for the extraction of the head from 
the uterus. The instances in which it is expelled by the natural efforts 
are few, and no confidence can, for obvious reasons, be placed in the 
occurrence of such a result. In some cases, it has been successfully 
removed, when compressible from putrefaction, by the fingers of the 
operator ; but, in almost all ordinary cases, instrumental aid is re- 
quired, when we have the forceps, the blunt hook, the crotchet, and 
the cephalotribe to select from. 

The great obstacle, in such cases, arises from the mobility of the 
head, which rolls about within the cavity, and can sometimes only be 
seized with difficulty. If, however, the head can be steadied and pressed 
downwards by the assistant, whose hands are employed for this purpose 
in the hypogastric region, the difficulty in question may be overcome. 
If it be possible to fix the crotchet, or a small blunt hook, in the 
foramen magnum or orbit, success may, in this way, with the aid of 
the fingers, be quite practicable; but the risk of the crotchet slipping 
is so considerable, that the more experienced modern operators have 
pretty much discarded that instrument in favor of the others which 
have been mentioned. The safest and most satisfactory operation, 
when it is practicable, is that by the ordinary midwifery forceps. The 
difficulty in this, as in the other operation, is to fix the head; for, as 
soon as one blade is introduced, the head may escape to the upper part 
of a relaxed uterus, or to either side, so as completely to elude the grasp 
of the blades; but if we can succeed in seizing the head, either antero- 
posteriorly or laterally, delivery will usually be completed without any 
further obstruction. The only other point to which it is necessary to 
pay particular attention, is the adjustment of the blades in such a 
manner as may obviate the possible danger arising from jagged spicula, 
which may project from the severed vertebra?, or from such splintering 
elsewhere as may possibly have been the result of previous operative 
efforts. 

There are cases, however, in which much more serious difficulties 
attend the extraction of the retained head. The worst examples of 
this are instances in which there is pelvic deformity, and in which it 



. 



XXX.] REMOVAL OF THE HEAD. 509 

may be quite impossible for the ordinary diameters of the head to pass. 
In these, and in the more diffieult of the cases unconnected with pelvic 
distortion, it has been suggested that the perforator should be used. It 
is to be feared, however, that, even in the hands of the most skilful, 
great risk will attend the use of that instrument ; and, even if it were 
not so, it must be admitted that the operation is one which we would 
not, without great apprehension, intrust to the inexperienced. Hazard- 
ous as the perforator always is, it is in this instance peculiarly so, owing 
to the mobility of the head, in consequence of which it may rotate 
suddenly and unexpectedly at the moment of perforation, and thus 
direct the sharp point of the instrument against the uterine wall with 
possible results too fearful to contemplate. If we are able, by means 
of external manipulation, to fix the head against the brim, the per- 
forator may be successfully employed against the occiput ; but, as mere 
pushing force would most likely dislodge the head, it is proper to com- 
bine boring with the more violent effort, which will, certainly, in econo- 
mizing the latter, conduce to the safety of the operation generally. 
After perforation, and evacuation of the contents of the cranium by a 
process exactly similar to that which will be described under the head 
of Craniotomy, the extraction of the head by the guarded crotchet, or 
still better, by the craniotomy forceps, will be a matter of no great 
difficulty ; but, in both cases, the greatest possible care should be taken, 
as the head descends, to preserve the soft parts from laceration by the 
splintered fragments of the bones. The Cephalotribe is an instrument 
for which, in the management of such cases, we must express a very 
decided preference, as being both safer and surer than either the per- 
forator or the crotchet, and almost as simple as the forceps in its appli- 
cation and management, as will be hereafter explained. And, after 
discharging its special office of crushing the head, which is of such 
importance in contraction of the brim, the cephalotribe may further be 
employed as an extractor. The crushing process may be single or 
double, but in either case the hold obtained by the blades of the instru- 
ment gives a grasp of such power that extraction may then be an easy 
matter. In this case, as in that of the forceps, the difficulty is in 
steadying the head until the blades are passed and locked. 

It is not only as a sequel to the operation of decapitation that extrac- 
tion of the head has to be effected ; but it is also sometimes required 
under other circumstances, such as its accidental separation after the 
operation of turning. This is not likely to occur in experienced hands, 
but the separation of the neck of a putrid child does not require much 
force, and might happen to any one. Far less excusable are the cases 
in which, in a breech presentation, or after turning, the head is arrested 
at the brim, and such violence is used in attempts at extraction as to 
result in tearing the trunk away from the head. In the absence of 
evidence of the death of the child, it is scarcely to be conceived that 
any one would use such violence as would of itself sacrifice the life of 
the child. But, if the child be dead, the operator might imagine that 
this is the safest and most natural method of delivery, and act accord- 
ingly by employing an amount of force which, in the interests of the 
mother, is quite unjustifiable, even should he succeed in his endeavor, 



510 TURNING. [CHAP. 

seeing that he has, in the forceps and the perforator, agents by which 
maternal risk is materially reduced. As an illustration of what igno- 
rance and inanity may achieve under the seal of the profession, we may 
here mention the details of a case of this kind, which was brought 
under our notice many years ago. A young practitioner in a remote 
country district having performed the operation of turning, experienced 
such difficulty in getting the head through the brim that he called in 
the aid of a friend of no greater experience than himself. Under the 
influence of vigorous efforts thus reinforced, the body of the child was 
brought into the world minus the h*ead. The removal of the retained 
head was too much for the combined skill of the two operators, so that, 
after repeated failure, they held a council ; and, after due and solemn 
consultation, resolved to perform, and actually did perform — what? — 
the most ingenious and speculative of our readers can scarcely conceive 
it — the Ccesarian Section ! 



CHAPTEE XXXI. 

TURNING. 

VARIOUS METHODS OF TURNING : TURNING AS PRACTICED BY THE ANCIENTS \ PO- 
DALIC VERSION — CIRCUMSTANCES WHICH CALL FOR, AND CONDITIONS FAVOR- 
ABLE TO THE OPERATION : THE OPERATION IN DETAIL : CHOICE OF HANDS : 
INTRODUCTION OF THE HAND: PASSAGE OF THE OS: SEIZURE OF A FOOT OR 
KNEE— CIRCUMSTANCES WHICH RENDER TURNING DIFFICULT : DIFFICULTY IN 
SEIZING THE FOOT — CHILD TO BE TURNED FORWARDS — MANAGEMENT OF THE 
CASE AFTER VERSION — PELVIC VERSION — CEPHALIC VERSION — TURNING IN 
CONTRACTED PELVIS : DEGREE OF DISTORTION WHICH MAY ADMIT OF TURNING — 
TURNING CONTRASTED WITH THE LONG FORCEPS, AND AS A SUBSTITUTE FOR 
CRANIOTOMY — SPECIAL DIFFICULTIES — BIMANUAL OR BIPOLAR VERSION : PRO- 
CESSES OF WIGAND, LEE, AND BRAXTON HICKS. 

The operation of Turning, in its most extended sense, implies a 
manoeuvre by which one of the poles of the long diameter of the child 
is brought into the brim of the pelvis, the long diameter of the foetal 
oval being thus made to correspond to the long diameter of the uterus. 
Two varieties of turning may therefore be practiced: these are turning 
by the head, or, as it is generally termed, Cephalic Version ; and turn- 
ing by the feet, or Podalic Version. A special modification of the 
latter, in which the breech, and not the feet, is brought down, has been 
occasionally practiced, and separately described. 

From the time of Hippocrates down to the middle of the sixteenth 
century, Cephalic Version was almost exclusively practiced, the head 
of the child being assumed to be the only natural presentation. This 
assumption led to the frightful practice of turning by the head in all 
presentations of the pelvic extremity. It is quite clear that both 



XXXI.] THE OPERATION. 511 

Aristotle and Celsus held more correct views ; but the practice of Hip- 
pocrates, nevertheless, held its ground until the period which we have 
mentioned ; so that, up to that time, the modern operation of turning, 
as practiced in the present day, was quite unknown. In 1561, Pierre 
Franco, in. a work devoted chiefly to Surgery, suggested the mode of 
turning by the feet, and this was subsequently adopted by Pare, Guille- 
meau, Mauriceau, Baudelocque, and La Chapelle, to the complete ex- 
clusion of the cephalic operation. The difficulties which, under certain 
circumstances, surround the modern operation, seem, as late as the 
end of last century, to have suggested doubts as to its propriety* in the 
minds of Flamand, Osiander, and other distinguished accoucheurs of 
that time, who therefore suggested that the practice of Hippocrates 
should be resorted to in all but original presentations of the breech or 
feet, to the exclusion, absolutely, of the new method. These views 
found favor chiefly in Germany, but the podalic method made steady 
progress, and came ultimately to be generally adopted. The con- 
temptuous manner, however, in which cephalic version was passed over 
or condemned by many of the most eminent writers of this period, led 
for a time to the complete abandonment of this process; but, in the 
present day, its value finds- general recognition in a certain class of 
cases, — limited, no doubt, in point of numbers, as will be more particu- 
larly shown in the sequel. 

What is now, however, universally described as, par excellence, the 
operation of Turning, is Podalic Version, which consists in bringing 
down the feet when another part presents, and thus converting it into 
a footling presentation. The circumstances which call for this opera- 
tion embrace a large proportion of all cases in which a speedy delivery 
is required, and especially those in which the necessity has arisen early 
in the course of labor. Among the circumstances thus alluded to, may 
be mentioned placenta previa, prolapse of the cord, sudden death of 
the mother, certain cases of rupture of the uterus, and, in the opinion 
of many, cases of moderate pelvic distortion, in which it has been pro- 
posed as a substitute for the forceps, or the more formidable operation 
of craniotomy. In transverse or shoulder presentations, again, it is the 
invariable procedure ; and, in so far as this particular case is concerned, 
it has already been described at some length. 

It is of the first importance that the conditions favorable to the 
operation should be correctly appreciated. As it is usually performed, 
it is essential that the os and cervix should be sufficiently dilated to 
permit of the passage of the hand ; but, as a moderate degree of dilata- 
tion only is requisite for this, it follows that turning is available at a 
stage of labor considerably earlier than we have seen to be necessary 
for the safe employment of the forceps. Another favorable condition 
applicable alike to all cases, is, that the membranes should be intact. 
The reason of this is obvious ; for, so long as the liquor amnii remains, 
the walls of the uterus are separated, in proportion to its quantity, 
from the body of the child, the mobility of which is consequently 
greater. Nothing, indeed, contributes so much to the ease with which 
turning is effected as this; and, if the waters have escaped, and the 
womb has thus been permitted to grasp the body of the child, the 



, 



'512 TURNING. [CHAP. 

operation is then found to stand in a very different category. The 
condition of the os as regards dilatability is another most important 
consideration, for a rigid or unyielding condition of this part of the 
passage is justly looked upon as an unfavorable circumstance, and it is 
therefore proper to wait, so long as the membranes remain unruptured, 
until nature overcomes this resistance. 

The Operation. — The condition of the bladder and rectum having 
been attended to, the woman is, in the first instance, to be placed in 
a convenient position. Some operators prefer that she should be on her 
back, and others that she should be on her elbows and knees ; but 
the English operator will generally choose the ordinary midwifery 
position on the left side, the nates being brought to the edge of the 
bed, so as to be within convenient reach. She should then be brought 
under the influence of chloroform. This has the effect of facilitating, 
both directly and indirectly, the passage of the hand, by overcoming 
rigidity and spasmodic contraction, and obviating the embarrassment 
which may arise from movements which are the result of apprehension 
or pain. The uterus is to be supported by an assistant, or by the 
other hand of the operator. By this means valuable assistance is 
afforded, by movements which are made in concert so as to bring the 
lower extremities of the child within reach. 

The directions which are often given as to the hand which should be 
employed are of little practical value. Indeed, it is impossible in some 
cases, as in placenta prsevia, to recognize, before it has been passed 
into the uterus, the conditions which are held to indicate the right 
hand or the left. Most people can act much more efficiently with the 
right than with the left hand, and there is no possible direction within 
the pelvis in which the right may not be passed. The positions in 
which there is most difficulty are those in which it may be necessary 
to direct the hand, with the palm forwards, towards the left sacro-iliac 
synchondrosis while the woman lies in the ordinary position on her left 
side. In this case the hand must be pronated to the fullest extent; 
and, if this movement of pronation is increased, as it may be by the 
operator turning his back towards the patient, it will pass without dif- 
ficulty. The left hand would undoubtedly serve the purpose better 
here, if we could be sure of equally efficient action with it after the 
introduction. But, if the operator is left-handed, he should use the 
left hand in preference to the right; and, as our first object is to attain 
the abdominal surface of the child, — which, in the great majority of all 
positions, lies towards the back of the mother, — and as it must clearly 
be easier to pass the left hand along the sacrum than the right, the left- 
handed operator has a certain advantage. For the same reason, he 
who is ambidextrous should use that hand which may best suit the po- 
sition of the child ; but, if it should be impossible to ascertain the posi- 
tion, he should select the left, as being more likely to conduct him to 
the anterior surface of the child's body. 

The operator should take off his coat, and bare his arm, so as to ob- 
viate, as far as is practicable, any inconvenience which may arise from 
pressure upon the muscles. The hand and arm are then to be liberally 
smeared with lard, and the points of the fingers, which are brought 



XXXI.] THE OPERATION. 513 

together like a cone,, are introduced within the vulva, and steadily 
pushed upwards in the axis of the outlet. In the event of unusual 
contraction at this stage, the obstacle will, to some extent, be overcome 
by separating the fingers, so as to stretch the parts. No such difficulty, 
however, usually exists, but a more important one is encountered as 
the knuckles approach the orifice of the vagina. This is increased by 
the action of the constrictor vaginae muscle, especially in those cases in 
which chloroform has not been administered; but the resistance, by 
the stretching action of the fingers, combined with moderate and un- 
remitting pressure, will speedily be overcome, when the rest of the 
hand will pass into the vagina, the muscles retracting upon it as it ad- 
vances, and ultimately grasping the wrist. It is at this stage proper 
to pause, which affords us an opportunity of more carefully examining 
the presenting part, and it may be, of ascertaining the direction in 
which the hand is to be passed, with greater certainty than can be 
attained by the finger only. 

The operator, bearing in mind the curve of the pelvic axis, now 
alters the direction of his hand, so that its advance may coincide more 
with the axis of the brim. His subsequent procedure will depend 
chiefly upon the condition of the os. If it is well dilated, soft, and 
distensible, the hand may be passed at once, and turning will probably 
be effected with such ease as may astonish the. inexperienced. But, if 
the os be comparatively undilated, or in any degree rigid, he must 
proceed more warily, so as to avoid the slightest approach to violence, — 
introducing first one, then two, and subsequently the remaining fingers, 
in the most cautious manner possible. It is generally said that, to 
warrant an attempt at turning, the os must be dilated to the extent of 
a crown-piece. This is, of course, only intended as an approximation ; 
and as much or more will depend on the dilatability, as upon the stage 
of actual dilatation. 

If the membranes are still unruptured, another object in avoiding 
abruptness in manipulation is to preserve the membranes intact. With 
this in view, therefore, we direct the fingers, so soon as they have passed 
within the os, between the uterine wall and the external envelope of 
the ovum ; and, the connection between those parts being lax, no great 
difficulty is generally encountered in passing the hand upwards, with- 
out rupturing the membranes, in the direction of the feet. 

No part of this process is, however, to be attempted, without refer- 
ence to the natural expulsive efforts. If the uterus is acting in the 
usual manner by rhythmical contraction, we should choose the period 
of relaxation for the advance of the hand ; but, so soon as the advent 
of a pain is announced by contraction of the uterine walls, the hand 
should be allowed to lie quite flat and inactive, with the palm towards 
the child, until the period of relaxation marks the moment when our 
efforts may be safely resumed. Any attempt at continuous effort is 
wrong in principle, and is, we may be sure, apt to cause laceration, 
and even rupture of the uterus. This rule is one which is not observed 
in practice so strictly as it ought to be, and the wonder is, that accidents 
are not more frequent than they actually are, in cases where force is 
employed by the operator with no reference whatever to anything save 

33 



514 



TURNING. 



[CHAP. 



the resistance which he encounters. It will, however, as must be con- 
fessed, often be found that the stereotyped direction to act during an 
interval, and pause during a pain, cannot well be adopted, for the 
simple reason that the contact of the hand excites the uterus to con- 
tinuous, or at best remittent action, so that if we are to wait for absolute 
inaction on the part of the uterus, we may abandon the effort altogether. 
Such continuous or spasmodic action as this may be, as we have seen, 
allayed by the administration of chloroform ; and, if it should persist, 
we may still succeed, although it is necessary, in such instances, to act 
with redoubled caution and deliberation. 

As soon as the hand has reached so high in the uterus that the 
inferior extremity of the child can either be felt, or may be assumed to 
be on. the same level, the sac of the liquor amnii may be ruptured, and 
the fingers passed in the direction of the foot or knee. The rupture 
of the membranes is easily effected, by an effort of the fingers or the 
action of the nails in the direction of the foetus, but with this the 
mechanical advantage of the liquor amnii is not lost, as it is still 
retained by the efficient plug formed by the arm which occupies the os 
uteri. This renders the actual version an easy matter. The fingers of 
the operator lay hold of a foot or a knee, which, in withdrawing his 
hand, he brings with him, choosing, if he can, a moment of uterine rest 
for the purpose,, and availing himself, if it be necessary, of the assistance 
of the other hand, which is to be applied externally. As this is being 
done, the original presentation retreats from the lower segment of the 
uterus, so that the turning part of the operation is complete. 

Much argument has been wast- 
ed as to the propriety of bringing 
down one leg or two. The sound 
rule in practice is, that when we 
succeed in securing one foot, we 
should never pause to search for 
the other ; as one is all that is 
necessary, unless, perhaps, in 
cases of pelvic deformity, which 
we shall afterwards more par- 
ticularly allude to. Nay, more 
than this, the descent of one leg 
has a positive advantage as com- 
pared .with two, as thus, by in- 
creasing the diameter of the 
pelvis of the child, the parts are 
more thoroughly dilated, so as 
to admit of the ultimate passage, 
rapidly, and with comparative 
safety, of the head of the child. 
And, as this is the stage at which 
the life of the child is most fre- 
quently compromised, it is as- 
sumed, that by abridging its 
duration, foetal life in the aggregate must, by this process, be saved. 




Podalic version. 



XXXI.] PODALIC VERSION. 515 

Still, when a very rapid delivery is desired, the operator knows that he 
has a better and more efficient hold upon two limbs than he can have 
upon one ; and he will, therefore, very naturally, bring down both 
when they are within easy reach ; but, when the discovery and seizure 
of the other limb involves extra effort or delay, not even in such a 
case as this should he be otherwise than content with what he has 
already achieved. 

Constriction of the vaginal orifice, and incomplete dilatation of the 
os, are, as we have seen, difficulties which are often encountered in 
attempts at turning. Far more serious than those are the obstacles 
which we meet with, when the conditions which we have indicated as 
favorable to the operation do not exist. A case, for example, may be 
brought under our notice for the first time at an advanced period of 
labor, in which the os has been permitted to dilate, the membranes to 
rupture, and the presenting part to descend in the pelvis before the 
nature of the case has attracted particular attention, or the necessity for 
turning has been recognized. The most familiar illustrations of this 
are shoulder presentations, already described. In such cases, the liquor 
amnii has, we shall suppose, long since escaped ; the uterine walls have 
grasped the child in a firm embrace ; and the long-continued uterine 
action has forced the shoulder down into the cavity of the pelvis. If 
pelvic distortion should exist, impaction may have taken place; but, 
independent of this, mere tonic uterine contraction may so wedge the 
head as to render the case practically as bad as one of real impaction. 
In such cases, the difficulties are often insurmountable, for the operator 
cannot even pass his hand beyond the presenting part, and is obliged 
to desist, or have recourse to some of the other operations of midwifery. 
It is perfectly impossible to describe what experience alone can teach — 
the amount of force which, in this, or any other stage of the operation, 
we are warranted in employing. Anything even approaching to what 
we would call violence, is not only improper, but ineffectual, so that 
moderate and sustained effort, combined with an insinuating movement 
of the fingers, should always be preferred, as being comparatively both 
efficient and safe. If, for example, we were rudely and recklessly to 
thrust the hand into the vagina without observing the precautions we 
have detailed, we should, in all probability, inflict severe laceration on 
the parts ; but if, on the contrary, we act with caution and discretion 
in a case precisely similar, we effect our purpose with ease and safety. 
The same principle obtains, and should never be lost sight of, in all the 
subsequent stages. 

Impaction implies resistance from the pelvic walls; but we have 
obstacles of a not less insurmountable kind in the rigid condition of the 
os or uterine walls, when, although success by violence may be possible, 
it is only to be effected by what involves serious risk to the mother. 
It is such considerations, therefore, based on general principles, which 
should be our guide in practice, and deter or encourage us in an indi- 
vidual case. It not unfrequently happens, as practice has taught every 
experienced accoucheur, that these successive stages of difficulty have 
been, one by one, surmounted, and yet, at the very moment when 
success seemed just within our grasp, further progress was arrested. 



516 TURNING. [CHAP. 

The tips of the fingers may even touch the knee or foot, and yet the 
inch or so of further advance which is required can scarcely, by any 
moderate effort, be achieved. This is a moment at which, in our 
eagerness, we are apt to pass the line which separates prudence from 
rashness. By a vigorous thrust of the arm, we may be confident that 
we shall attain what we so much desire; and it is with difficulty only 
that we can refrain from what alone seems wanting to complete success. 
We must, however, with firmness, and what we may term self-denial, 
resist this inclination, and wait a little until, perchance, we may wear 
out the uterine resistance which constitutes the barrier to our progress. 

It is here, however, most unfortunately, that the straining of the 
fingers is apt, along with violent uterine contractions, to cause cramp 
of the muscles of the hand, a condition which may absolutely paralyze 
our efforts. By resting for a time, or stretching the fingers, the power 
of the hand may return ; but it too often occurs that we find ourselves 
quite powerless just at the moment when we have come to count upon 
success crowning our efforts. Nothing will remain for us, in such a 
case, but the withdrawal of the hand, to our great chagrin, and either 
the introduction of the other, or the reintroduction of the same one 
after it has had time to recover. What is particularly annoying, when 
this is found to be necessary, is that the withdrawal of the hand from 
the uterus permits of the escape of what liquor amnii remains, and, 
consequently, of a still greater degree of uterine contraction upon the 
body of the child. Even in such a case, however, we may ultimately 
succeed by perseverance; and, when the hand has again been introduced, 
our external manipulations may result in bringing the feet within reach. 
But, with this measure of success, our difficulties may be far from being 
at an end. 

It sometimes happens that the hand is introduced, the foot seized 
and brought down to the os, and yet complete version cannot be 
effected. When the presence of the liquor amnii, or a relaxed condi- 
tion of the uterine walls, permits of a certain degree of freedom of 
motion, the presenting part will recede as the foot is pulled downwards 
to the os. But, when the body of the child is firmly grasped by the 
uterus, this is not the case, and some further manoeuvring, external or 
internal, will be required to complete the operation. The mode of acting 
externally through the abdominal w T alls has already been alluded to, and 
will again be more particularly described. The internal manipulation 
in these cases consists in pushing up the presenting part while we pull 
down the foot. In other words, we act upon the two poles of the long 
diameter of the foetus instead of one only. The vagina, however, being 
already fully occupied by the hand of the operator, it will be impossible 
for him to act upon the presenting part without letting go the hold 
which he has of the foot ; but this is of all things what he least wishes 
to do, as there is often great difficulty in securing it again. By a very 
simple expedient he is able to effect all that he desires. A. running 
noose of tape or worsted is to be passed over the forearm, and is then 
pushed upwards over the hand and beyond the os calcis and instep of 
the foot. When tightly drawn, this secures an admirable hold, and 
the hand may be withdrawn, or at once brought to bear upon the head 



XXXI.] 



TURNING BY THE NOOSE OR FILLET. 



517 



or presenting part, while the other hand pulls steadily upon the noose. 
The same principle has been adopted, by Braun and other eminent 
Continental practitioners, when difficulty arises in seizing the foot, and 
various instruments have been devised by them with this purpose. 



Fig. 176. 




Turning by the noose or fillet. 



One of these is described by Hyernaux of Brussels, under the name of 
porte-lacs. When such combined action upon the two extremities of 
the child fails, it may be impossible to effect delivery in this way ; so 
that we may have to fall back upon the perforator or decollator, as the 
case may be. Before finally abandoning the attempt to deliver by this 
method, w r e must be sure that we have pulled down the foot in the 
proper direction, so as to turn the child forwards. An error here is 
not likely, as we would naturally pull the foot, when seized, directly 
towards the os ; and if we have passed the hand along the abdominal 
surface, we can scarcely go wrong; but it is quite possible that, by 
omitting this precaution, and passing the hand over the dorsal surface, 
we may not only find it vastly more difficult — if, indeed, it be possible 
— to reach the foot, but we may discover, in addition, that when it is 
reached and seized, turning is impracticable after all. 

It is generally recommended by systematic writers, that we should 
so manage the operation as to make sure that the abdomen of the child 
is turned, after version, towards the spine of the mother, as is indicated 
by the toes being directed towards the sacrum. This is, however, by 
no means a matter of such importance as it might appear, for if, as 
often happens, the toes should be pointed to the symphysis pubis, the 



518 TURNING. [CHAP. 

trunk of the child will rotate as it descends, so as to bring the face 
ultimately into the hollow of the sacrum, whatever the original posi- 
tion may have been. But, when the natural rotation has not taken 
place, it has been found necessary to assist the movement by manual 
interference. The greatest caution must, in every case, be exercised, 
to prevent, as much as may be possible, pressure upon the cord ; but, 
in so far as this is concerned, what has already been said in regard to 
presentations which are originally of the pelvic extremity, will serve 
for our guidance in those cases in which the pelvic end of the fetal 
oval is artificially, and for a particular purpose, brought down. One 
advantage of effecting version, so as to bring the dorsal surface to the 
front, will be to bring the cord naturally into the posterior part of the 
pelvis from the first, by which we are enabled to place it in that situa- 
tion in which it is least likely to be subjected to severe pressure. 

When version is complete, we have converted the case, whatever it 
may originally have been, into a presentation of the feet. It remains, 
however, for consideration, whether w r e are to leave the case to nature, 
or proceed to immediate delivery. It is almost always proper to pause, 
at least for a time, until we see what nature is likely to do ; but, if the 
symptoms are such as to call for prompt action, whether in the interests 
of the mother or the child, we must act boldly, and without hesitation, 
in effecting immediate delivery. It should be remembered, that so 
long as the head of the child remains above the brim, the cord is not 
likely to be subjected to any dangerous pressure, so that, while nothing 
is lost by delay at this stage, something may be gained by pausing 
until uterine energy is awakened. If the cord has prolapsed, or has 
otherwise come within reach, at this or a subsequent stage, we will be 
guided by the presence or absence of pulsation, and the other evidences 
of vitality of the fetus, in determining whether to precipitate matters 
or not. During the descent of the trunk, we must observe the usual 
precautions, but at the last stage there must be no delay, and the for- 
ceps and restoratives should be at hand, so that we may at once have 
recourse to them should occasion arise, and that in the manner described 
in the chapter on Pelvic Presentations. 

The term Pelvic Version, as employed by English writers, implies 
an operation in which the breech, and not the feet, is brought to the 
os when another part originally presents. That this may, in rare 
instances, be effected by dexterous management, does not admit of dis- 
pute ; but, at the same time, such a course of procedure is so obviously 
one of greater difficulty, as compared with podalic version, that we need 
not wonder that the former operation, which, indeed, never attracted 
much notice, has been all but entirely superseded by the latter. As 
regards the ancient operation of Cephalic Version, it seems certain 
that there are cases of transverse presentation in which we would be 
justified in making an attempt at what is a less severe operation to the 
mother, by pushing up the shoulder, and so manipulating as to cause 
it to be replaced at the os by the head. Success could here only be 
hoped for when the child is still movable within the uterus, and the 
method most likely to be attended with success is what has been desig- 



XXXI.] PELVIC VERSION. 519 

nated by Braxton Hicks and others, as the "bimanual" or "bipolar" 
method, — to be afterwards described. 

The application of the operation of ordinary or podalic version to 
cases of pelvic contraction, is a mode of procedure which was practiced 
long before the forceps was discovered. Nor did the discovery of that 
important instrument throw the earlier operation entirely into the 
shade; and, indeed, we find Denman, and other contemporary writers, 
giving minute directions, a hundred years ago, as to the manner in 
which the operation is, under such circumstances, to be effected. There 
can be no doubt, however, that as operators became more skilled in 
the use of the forceps, and the scope of that instrument became more 
thoroughly understood, the number of cases of contracted pelvis in 
which turning was practiced, was more and more diminished, until, at 
last, the operation fell into complete disuse. In the present day, the 
operation has been revived and strenuously advocated by Simpson; 
and, although some experienced operators have condemned it, it is the 
fact that many of the most distinguished living accoucheurs have 
adopted his views and practice. Simpson maintained his position by 
arguments and facts, — the former being characterized by the ingenuity 
and ability which he possessed in such a high degree, and of which 
his works afford no more striking illustration. 

The fact that this operation involves a question of conservative mid- 
wifery, is one which may alone suffice to secure for the subject earnest 
and careful attention ; and this, indeed, it has received from almost all 
recent writers. In cases in which the head is arrested by pelvic con- 
traction at the brim, we have three possible modes of action between 
which we must decide, — turning, forceps, or craniotomy. The two first 
are conservative, the last destructive. The dangers and difficulties of 
the long forceps are well known, and have been fully described; but 
there are, probably, few operators who would not rather risk them than 
wantonly destroy a living child, as we have too good reason to believe 
has often been done. The case is quite different when the child is 
dead ; for here we determine upon a plan of action which we under- 
take solely in the interests of the mother, when craniotomy stands 
before us under quite another aspect. The first point of importance, 
then, is to determine whether or not the child is alive; and if, this 
being established, we fail to deliver by the long forceps, or that instru- 
ment is contraindicated, the question before us simply is : Shall we 
turn, or perforate — attempt to save the child, or at once destroy it? 

The reply to this question, involving as it does such weighty 
responsibility, will depend upon a variety of circumstances, of which 
the most important, perhaps, is the degree of pelvic distortion which 
actually exists. It is impossible to fix the exact measurement of the 
conjugate diameter which may be held to warrant an attempt at turn- 
ing; and, even were it possible to determine this with fractional accu- 
racy, our modes of practicing pelvimetry are so uncertain, that it is a 
matter of the greatest difficulty, even to the most dexterous, to gauge a 
pelvis during labor. Dr. Churchill fixes the limit at two inches and 
six-eighths, and Dr. Barnes, — as we believe, with more justice, — at 



. 



520 TURNING. [CHAP. 

from three and a quarter to three and three-quarters inches ; so that we 
may say, in round numbers, that when the conjugate diameter is less 
than three inches, to attempt to turn would be to subject the woman to 
needless risk, while we may be confident that nothing but failure could 
attend our efforts. 

But, seeing that this is a question where an eighth of an inch may 
make all the difference between success and failure, and it is impossible 
to ascertain the exact space with anything more than what is at best an 
approach to accuracy, it follows, as a possible contingency, that we may 
actually turn, and subsequently find that we have miscalculated either 
the conjugate diameter or the size of the head, and that the latter will 
not pass. Such a failure as this is not so serious a matter as might 
at first sight appear; for if we have thus to resort ultimately to 
craniotomy, that operation will be attended with very little more diffi- 
culty and no greater risk than if we had begun by perforating the 
vertex. The mother, no doubt, has been subjected to the risks of 
turning in addition to those of craniotomy, but we are surely warranted 
in incurring this additional risk in the hope, if successful, of saving the 
child. 

Let us now examine shortly the positive advantages which are 
claimed by Simpson for the operation of turning in contracted pelvis. 
The biparietal measurement of the head is, as he points out, greater 
than the bimastoid ; and as, in turning, the latter enters the contracted 
space first, he argues that, on obvious mechanical principles, the com- 
pressibility of the head is increased by version ; and, as it is well known 
that in some cases of this kind, when the child has been born alive, the 
parietal bones have been found to be flattened, indented, or even frac- 
tured, he concludes that turning under such circumstances is not only 
a reasonable proposal, but an actual gain in facility of delivery and 
safety to the child. He goes, however, too far, and attempts to prove 
too much, when he maintains, as a corollary to this proposition, that 
the effects of the uterine contraction, when it forces a presenting head 
against a contracted brim, is to bulge outwards the biparietal poles, 
and thus increase the mechanical difficulty with the progress of labor. 

Simpson's theory has been contested by McClintock, E. Martin, and 
others, upon the whole, we think, unsuccessfully ; while, in corrobora- 
tion of his views, a considerable weight of practical evidence has 
accumulated, of which the following from Barnes's lectures is a striking 
illustration : " In the first place, let me state a fact which I have often 
seen. A woman with a slight contracted pelvis, in labor with a normal 
child presenting by the head, is delivered, after a tedious delay, spon- 
taneously or with the help of forceps ; the head has undergone an 
extreme amount of moulding, so as to be even seriously distorted. 
The same woman in labor, again, is delivered breech first; the head 
exhibits the model globular shape, having slipped through the brim 
without appreciable obstruction. In the second place, I have, on 
several occasions, been called to an obstructed labor in which the head 
was resting on a brim contracted in the conjugate diameter. Of 
had failed; the vis a tergo was insufficient. I have 






XXXI.] IN CONTRACTED PELVIS. 521 

tried the long double-curved forceps, trying what a moderate compres- 
sive power, aided by considerable and sustained traction, would do to 
bring the head through, and have failed. I have then turned, and the 
head coming base first, has been delivered easily. Upon this point I 
cannot be mistaken/ 7 

The operation of turning in contracted pelvis may thus present itself 
to us under two distinct aspects, — as a substitute for the long forceps, 
and as a substitute for craniotomy. As regards the former, the expe- 
rience of many independent observers would seem to show that, on the 
principle suggested by Simpson, turning may succeed when the forceps 
will fail; that instrument being, therefore, applicable to those cases 
only in which the contraction is moderate in degree. Owing to the 
difficulty of ascertaining the exact dimensions of the head and pelvis, 
a safe, and, we believe, a very general practice, is first to make a cau- 
tious attempt with the long pelvic-curved forceps, and failing that, — 
which, in skilful hands, is a safer operation to the mother, — to pro- 
ceed at once to turn. Turning as a substitute for craniotomy, is a more 
important point still — so important, indeed, in a conservative sense, 
that it cannot fail to command the attention of every conscientious 
practitioner. Impaction of the head, or difficulty of displacing it, so 
as to admit of the passage of the hand, and a degree of pelvic contrac- 
tion beyond the limit which we have stated, are the two principal 
contraindications of the operation of turning. The death of the child 
is not necessarily so, for craniotomy at the brim is by no means so safe 
an operation but that it may fairly be balanced against turning, even 
in the interests of the mother alone. 

The operator must be prepared, in turning in a contracted pelvis, to 
encounter special difficulties in individual cases, which it is impossible 
fully to describe, or even to anticipate. Following the example of all 
writers on the subject, we have alluded to the operation in reference 
only to simple conjugate contraction at the brim, by far the most com- 
mon of all the varieties of distortion. It requires no argument to show 
that rules applicable to this alone must often fail. In the typical mal- 
acosteon pelvis, we may find an actual increase in the conjugate 
diameter, coupled with such deformity as may render craniotomy, or 
possibly the Caesarian operation, the only practicable methods of deliv- 
ery. In those cases in which there is a symmetrical distortion, it is of 
importance that the large or occipital end of the head should, if possi- 
ble, be thrown into the larger half of the pelvis. To effect this is, 
however, a matter of very considerable difficulty ; and, we apprehend 
that the rules laid down by E. Martin and others for effecting the ob- 
ject cannot be held as being of much practical value. The accoucheur 
must in no case lose sight of the infinite varieties of distortion to which 
allusion has already been made, as these may at any time call for spe- 
cial adaptations, to which thorough operative capacity and an intimate 
knowledge of the subject can alone guide us. Another possible diffi- 
culty we have known to occur in connection with twin pregnancy, in 
which the operator, after introducing his hand, has seized the foot of 
the wrong child. 



. 



522 TURNING. [CHAP. 

The operation to which alone we have hitherto alluded, is the ordi- 
nary operation of turning, necessarily involving the introduction of the 
whole hand within the cavity of the womb. There is, however, another 
operation, or rather a modification of this operation, which may be 
practiced with less risk to the mother, and even, as it would seem, 
under circumstances which would render the ordinary procedure diffi- 
cult, if not impossible. This is Bimanual or Bipolar Version, an 
operation which is attracting, year by year, more and more of the 
attention which it merits. Early in the present century, Wigand sug- 
gested a method whereby the presentation of the child could be altered 
without the slightest risk to the mother, by external manipulation 
alone. His observation applied to transverse presentations only, and 
his plan was, — having ascertained, by vaginal examination, the exact 



Fig. 17' 




Malacosteon pelvis. 

position of the foetus, — so to press upon the child externally as to bring 
to the os uteri that pole of its long diameter which was lowest in the 
pelvis. In a word, he claimed to be able to practice both cephalic and 
podalic version, without even introducing a finger into the vagina, 
although he seems to have employed the inner hand to guide or receive 
the head or breech into the os. The directions which he gives include 
elaborate, but, we fear, impracticable instructions as to the manner in 
which we should proceed — with the view of availing ourselves, to the 
utmost, of gravitation — to place the patient, now on one side, and again 
on the other, at various successive stages of the operation. It is quite 
certain that Wigand never contemplated anything more than partial 
version, so that his novel manoeuvre, which found considerable favor 
in Germany, was never supposed to be applicable to cases of placenta 
previa, nor to any other case in which the head was originally the 
presenting part. 

Dr. Robert Lee seems to have been the first to suggest a method of 
turning, which is the opposite of that to which Wigand lent the weight 
of his authority. In cases of incomplete dilatation of the os uteri, he 



L 



XXXI.] BIPOLAR METHOD. 523 

brought two fingers, which he passed into the uterus, to bear upon the 
head, which he first of all attempted to displace; and, when he had 
succeeded in this, he successively pushed aside those parts which came 
opposite the os in the same direction as that in which the head had 
disappeared, until, ultimately, the feet were made to present, or were 
brought within reach of the finger, and so secured. We owe, however, 
to Dr. Braxton Hicks the method of combined external and internal 
version, which bids fair to supersede, in a great measure, the old 
method, and for the expediency of which we can unhesitatingly, and 
from personal experience, vouch. The conditions which have already 
been mentioned as favorable to ordinary podalic version, are even more 
essential to the successful performance of the bipolar method. Unless, 
therefore, the child is movable with tolerable freedom within the uterus, 
we can scarcely expect to succeed in effecting version by this, as we 
should probably fail by the other method. But, until we have thor- 
oughly tried the effect of chloroform in reducing rigidity and tonic 
contraction of the uterine fibre, we should not too readily abandon the 
chance which this operation may possibly afford us, and we may be 
sure that if, at any stage, the conditions which are generally considered 
to be favorable to the ordinary operation are manifested, we may hope 
to succeed by this process. The operation of Braxton Hicks is, as will 
be inferred, a combination of the methods of Wigand and Lee, in the 
course of which, while the operator brings one hand to bear upon the 
uterus through the abdominal walls, he simultaneously operates upon 
the other end of the child by means of the finger, which he has intro- 
duced into the vagina and through the os uteri, causing the one pole 
to descend, as he encourages the other to recede. 

In so far as transverse presentations are concerned, we are indebted 
to Dr. Robert Lee for having first clearly pointed out that when the 
child is situated quite transversely within the womb, its knee is gen- 
erally within a finger length of the os uteri, and thus in some trans- 
verse presentations, it is not very difficult to hook down the knee. 
The child, however, as both he and Wigand have shown, does not 
usually lie transversely, but rather obliquely in regard to the trans- 
verse axis of the uterus, which removes the knee to some extent from 
the immediate grasp of the finger, and brings at the same time the 
operation of cephalic version somewhat more w T ithin the range of pos- 
sibility. But, while we thus recognize, as we can scarcely fail to do, 
the advantage of the bimanual method over either of those in which 
one pole only is acted upon, the former admits, as will be seen, of a 
far more extended application, such as was never sought to be accom- 
plished, so far as we can see, either by Wigand or Lee. In cases of 
placenta prsevia, therefore, or in cases of contraction of the brim of 
not less than three inches in the conjugate diameter, the head being 
the presenting part, it is quite possible, and in some instances by no 
means difficult, to effect complete version by the bimanual method, 
and thus avoid many of the risks of the ordinary operation. For the 
details of this procedure we shall here quote the directions of Dr. 
Braxton Hicks. 

" I will now proceed to describe the mode by which I effect po- 



524 



TURNING, 



[CHAP. 



dalic version. We will suppose a case where everything is natural ; 

the os uteri dilated to admit 
FlGl7S - one or two fingers, membranes 

perfect, and the face towards the 
right side. The patient may be 
placed in the ordinary obstetric 
position. Having lubricated my 
left hand, I introduce it as far 
into the vagina as is necessary, 
in order to reach a finger's 
length within the cervix. Some- 
times it requires the whole 
hand, sometimes three or four 
fingers will be sufficient in the 
vagina. Having clearly made 
out the head and its direction, 
whether to one side or other of 
the os uteri, I place my right 
hand on the abdomen of the 
patient towards the fundus ; I 
then endeavor to make out the 
breech, which is seldom a diffi- 
cult matter. The external 
hand then presses gently but 
firmly the breech to the right 
side ; as it reeedes, so the hand 
follows it either by gentle pal- 
pation, or by a kind of, gliding 
movement over the integuments, 
while at the same time the 
other hand pushes up the head 
in the opposite direction, so as to raise it above the brim. It may be 
mentioned that, when the head has descended a eonsiderable distance 
into the pelvic cavity, or more than half way through the os uteri, it is 
scarcely possible to lift it above the brim, especially if the uterus be 
active. 

" When the breech has arrived at about the transverse diameter of 
the uterus, the head will have cleared the brim, and the shoulder will 
be opposite the os. That is pushed on in like manner as the head, and 
after a little further depression of the breech from the outside, the knee 
touches the finger, and can be hooked down by it. It very frequently 
happens, when the membranes are perfect, that, as soon as the shoulder 
is felt, the breech and foot come to the os in a moment, in consequence 
of the tendency of the uterus to bring the long axis of the child coin- 
cident with that of its own. Should it, therefore, be difficult to hook 
down the knee, depress the breech still more, and it will be almost 
always the case that the foot will be at hand. 

" It will, sometimes, render turning more easy if, as soon as the head 
is above the brim, we pass the outside hand beneath it, and push it up 
from the outside alternately with the depression of the breech. All this 




Bimanual version: first stage. 



XXXI.] 



BIPOLAR METHOD. 



525 



can generally be performed in a much less time than I have taken to 
describe it, although in some it requires gentle, firm, and steady perse- 
verance, with such a supply of patience as is always demanded in ob- 
stetric operations. If the os will only admit one finger, and the foot 
cannot be brought through in consequence, it can yet be retained at the 
os by pressing it with that finger against the inner surface of the os; 
the most convenient part being against the anterior part, because the 
pubes will assist in supporting the pressure, while, at the same time, in 
most persons, unless very stout, the band pressing externally above the 
pubes is capable of assisting materially in retaining the leg in that posi- 
tion, and securing the altered change, ready for us to take advantage of it, 
should the case so require, as soon as the os dilates sufficiently ; and 
the mere retention of the leg here is of considerable value, for, in cases 
of turning, even when we cannot effect turning immediately after 
having seized one of the limbs, yet the holding on to that part, and 
thereby fixing it, ultimately produces such an improved relationship 
between the uterus and its contents that the after operations succeed 
more easily. Should the child face towards the left side, the only dif- 
ference required in operating is, that the breech be pressed towards the 
left side, and the head to the right." 

Further on, in regard to Cephalic version, Dr. Hicks continues: 



Fig. 17;). 



Fig. L80. 




Second stage 



Third stage 



"We will suppose, first of all, a case where the uterus is not active, the 
liquor amnii not escaped, or only recently so, where the foetal head has 
not passed the os. Introduce the left hand into the vagina as in po- 



L 



526 EMBRYOTOMY. [CHAP. 

dalic version ; place the right hand on the outside of the abdomen in 
order to find the position of the fetus, and the direction of the head and 
feet. Should the shoulder, for instance, present, then push it with one 
or two fingers through the cervix in the direction of the feet. At the 
same time, pressure by the outer hand should be exerted on the cephalic 
end of the child. This will bring down the head close to the os ; then 
let the head be received upon the tips of the inside fingers. The head 
will play like a ball between the two hands ; it will be under their 
command, and can be placed in almost any part at will. Let the head, 
then, be planed over the os, taking care to rectify any tendency to face 
presentation. It is as well, if the breech will not rise to the fundus 
readily after the head is fairly in the os, to withdraw the hand from 
the vagina, and with it press up the breech from the exterior. The 
hand which is retaining gently the head from the outside should con- 
tinue there for some little time, till the pains have insured the retention 
of the child in its new position by the adaptation of the uterine walls 
to its form." * 

We shall make no apology to the reader for the length of this ex- 
tract, and the prominence which we have thus given to the operation of 
bipolar version, as we look upon it as one of the most important im- 
provements in modern obstetrics, which is attracting an amount of 
attention ever on the increase, and which is, if we mistake not, likely 
ere long, to take the place of the more familiar procedure of ordinary 
podalic version. 



CHAPTEE XXXII. 

EMBRYOTOMY. 

CONDITIONS WHICH "WARRANT THE OPERATION — CRANIOTOMY: CONSISTS OF VARI- 
OUS STAGES — PERFORATION : VARIETIES OF PERFORATORS : METHOD OF, AND 
PRECAUTIONS TO BE OBSERVED IN PERFORATING — CRANIAL CONTENTS TO BE 
BROKEN UP AND DISLODGED — TRACTION TO BE NOW EMPLOYED — USE OF THE 
CROTCHET: WHERE TO FIX IT: DANGERS OF — THE GUARDED CROTCHET — THE 
CRANIOTOMY FORCEPS — REMOVAL OF THE VAULT OF THE CRANIUM — PROTEC- 
TION OF THE MATERNAL TISSUES — DAVIS'S OSTEOTOMIST — THE SCALP TO BE 
PRESERVED — TURNING AFTER CRANIOTOMY — CANTING THE BASE, AFTER RE- 
MOVAL OF THE FLAT BONES, AND BRINGING THE FACE DOWNWARDS — THE 
CEPHALOTRIBE : FRENCH AND ENGLISH MODELS— CEPHALOTRIPSY THE FINAL 
STAGE IN THE OPERATION OF CRANIOTOMY — DETAILS OF THE OPERATION — MAY 
THE CEPHALOTRIBE BE USED AS A TRACTOR? — SUBSEQUENT EXTRACTION OF 
THE TRUNK — CRANIOTOMY IN BREECH DELIVERY, AFTER THE PASSAGE OF THE 
TRUNK — EMBRYULCIA: EVISCERATION OF THE FCETUS : APPLICABLE CHIEFLY 
TO IMPACTED TRANSVERSE PRESENTATION — VAN HUEVEL'S FORCEPS SAW— DR. 
BARNES'S PROCESS OF CRANIAL SECTION BY THE ECRASEUR. 

Embryotomy is, in one sense, the most objectionable of all the 
operations of Midwifery ; for, of all other possible modes of procedure 

1 On Combined External and Internal Version: by J. Braxton Hicks, M.D., 
F.R.S.,etc. London, 1864. 



XXXII.] 



CONDITIONS REQUIRING CRANIOTOMY. 



527 



this is the one which most certainly involves destruction of the child. 
( )n this account, the accoucheur shrinks, with natural repugnance, from 
an operation which necessarily implies mutilation of a dead, and must 
destroy a living child. Such, however, is a view which we are apt to 
carry to an extreme, and overlook, in so doing, the more important 
Interests of the mother; while we forget that circumstances do arise, 
when in full knowledge of the fact that the foetus lives, it may be the 
duty of the accoucheur unhesitatingly to sacrifice the child, as this is 
the only means by which he may reasonably expect to save the mother. 

Our first and earnest, desire, of course, is to save, if it be possible, 
the child as well as the mother; but, if it should became obvious that 
all hope of a result so favorable must be abandoned, we may be sure 
thai we are fully justified in giving up the child, if we recognize in this 
the only mode of preserving the more important life. Nothing, of 
course;, will justify this, short of an absolute; conviction that the vectis, 
the forceps, and turning, arc; of no avail ; for then, and then only, are 
we justified in laying aside the implements of conservative! midwifery, 
and taking into our hands agents which are; destructive to the; child. 
On the Continent generally, and especially in Roman Catholic countries, 
where the religion s element corrjes more; prominently into play, foetal 
Life is, it must be; confessed, more jealously guarded than with us. But, 
while we 4 fully recognize the humane impulses which may thus sway a 
purely scientific decision, it must be affirmed that, whenever it is cer- 
tain that a living child cannot pass, nothing can be; more irrational 
than to await the death of the child, before we act upon the conviction 
thai it cannot live, — and thus allow the period to pass at which we may 
confidently operate, in the expectation of preserving maternal at the 
sacrifice of foetal existence. 

However lightly, on tlu> other hand, we may view these considera- 
tions, evidence of the death of the' e'hilel will always be held as of para- 
mount importance, in all cases in which the operation of Embryotomy 
may oiler itself for our consideration. Wheai this is clear all scruples 
will vanish, as we have> the mother alone to consider; and, therefore, 
wheai the 4 other modes of procedure are 4 impracticable, we' will proceed, 
without hesitation, to the' performance of an operation which treats the; 
de>ael foetus as a, mass of inert matter, to be removed at the least pos- 
sible 1 risk to the> mother. 

The conditions, then, which may be held as warranting the- operation 
of Embryotomy are those in which the Forceps and Turning are of no 
avail, and which, at the same time, preclude the passage of a living 
child. In so far as contraction of the' conjugate diameter at the brim 
is concerned, we have' already seen that, in the' e*ase' of a fully developed 
child, we can scarcely ex peel a successful result from turning, when that 
diameter is much less than three inches ; and this, therefore, we may 
lake' as the' limit- within which the operation may be; demanded. Tu- 
inors of any kind, — bony, malignant, or ovarian ; atresia of any portion 
of (he ordinarily distensible canal ; impaction of the head, or extreme 
contraction of the uterus, are illustrations of other causes which, inde- 
pendently of ordinary pelvic distortion, may render delivery by embry- 
otomy the' only method from which we can anticipate u favorable result. 



L 



528 EMBRYOTOMY. [CHAP. 

Although the history of former labors is, in such cases, to be admitted 
as an important consideration, in determining our course of procedure, 
the conclusions of many independent observers show very clearly that 
this must not be allowed to take too prominent a position, as it not 
unfrequently happens that women who have had an ordinary labor 
before, under circumstances which are apparently similar, are, if not 
relieved, subjected in subsequent labors to the greatest peril. This may 
be due, according to Barnes, to progressive pelvic contraction, or, as 
D'Outrepont holds, to progressive increase in the size of the children. 
But, on the other hand, we may fall into the opposite error, if Dr. 
Matthews Duncan's deductions are correct, — that after women have 
attained the age of twenty-nine, the weight of their children falls, — 
by supposing, that because craniotomy was found necessary on a former 
occasion, it must necessarily be required in subsequent pregnancies 

which have been allowed to go to the full time. Amon^ the rarer 

. . . 

conditions demanding craniotomy, are impacted mento-posterior posi- 
tions of the face, cases of locked twins, in which one head can only be 
released by perforating and reducing the bulk of the other, double- 
headed monsters, and hydrocephalus. 

There are, however, in addition to these, certain conditions of the 
mother which may call for the operation. It has already been shown 
that, in cases in which, from any cause, speedy delivery is required, 
turning is to be preferred to the forceps, when the dilatation of the os 
is not sufficient to admit of the safe use of that instrument: and to 
this it may now be added, that an even less degree of dilatation of the 
os will suffice for craniotomy than for turning, as all that is essential 
is space for the introduction of two fingers and the extremity of the 
perforator. In cases, therefore, of convulsions, great exhaustion, and 
some instances of rupture of the uterus as already particularized, in 
which the state of the os forbids both the forceps and turning, it may 
be necessary for us to perforate. As a rule, how T ever, and excepting 
the cases of rupture of the uterus alluded to, we should never operate 
by craniotomy while there is a possibility of nature prevailing, until 
we have given her a fair chance, and have waited to see what may be 
effected by the ordinary process of moulding. 

The condition of the parts, or the stage of labor at which the opera- 
tion should be performed, is a matter of great importance, less perhaps 
in regard to the mere facility with which it may be effected than with 
reference to the safety of the woman. Although as has been observed, 
a very moderate dilatation of the os is all that is essential, it affords 
great comparative facility to the operator, and proportionate safety to 
the mother, if the head is divested to a great extent of the covering 
which, in the early stage of labor, it derives from the lower segment 
of the uterus. It is of even greater importance that the head should 
have descended, to some extent, into the pelvis, and be within easy 
reach ; for the operation upon a head which is still above the brim will 
be found, even under circumstances which are in other respects favor- 
able, to be a very different operation from that in which it is arrested 
within the cavity of the pelvis. There are conditions, however, which 
may render a case manifestly impracticable, or which may admit of 



XXXII.] 



PERFORATION. 



529 



doubt ; so that the peculiarities of individual cases must be our guide 
as to whether anything is to be gained by delay, and, if so, to what 
extent we are to maintain an expectant attitude. It is certain that we 
have less choice here as to the period which we may choose for the 
operation than obtains in regard to some of the other modes of proce- 
dure which we have described. 

The Operation. — Embryotomy almost always involves craniotomy, 
so that the two terms are often used as synonyms. Craniotomy has 
been often euphemistically described as " lessening the bulk of the 
head." It consists of several stages, some of which may alone be re- 
quired ; or it may be necessary, before effecting delivery, to go through 
the whole of them, one after the other. We purpose, therefore, to ex- 
plain these successive steps, as points in detail of one method of opera- 
tive procedure, according to the degree of pelvic distortion, or other 
circumstances which may constitute the special impediment, and in- 
cluding the use of the omphalotribe. 

The first step in all operations of craniotomy is Perforation, and for 
this various instruments have been devised, which are termed per- 
forators. The condition of the head, upon which its impact or resist- 
ance depends, is, in the first place, to be overcome, in order to permit 
of its collapse ; and it is with this object solely that we perforate, and 
so act otherwise as to admit of the escape of the 
contents of the cranium, so that the forces, natural fig. isi. 

or artificial, may be brought to bear upon a part 
which is now susceptible of a considerable diminu- 
tion in its diameters. The form of instrument 
which has by many Continental practitioners been 
preferred, is one which, in the principle of its con- 
struction, is almost identical with the ordinary 
trephine; but what is preferred and invariably 
used by English operators, is some modification of 
the perforating scissors of Smellie. The instru- 
ment here shown is that which was used by Simp- 
son, and which generally bears his name. It con- 
sists of two blades with shoulder-stops, the blades, 
when in apposition, forming a triangle of which 
the base is at the stops, with cutting edges, con- 
verging to a point, which is the apex of the triangle. 
The instrument is thus one which is to be used with 
the greatest possible caution, lest injury should be 
inflicted upon the soft parts of the mother. When 
the blades are separated by pressing the handles 
together, a powerful spring between the latter 
causes them to close so soon as the grasp is relaxed. 
[Mr. Holmes has also modified Smcllie's scissors by 
bending the handles so that they cross each other, Simpson's perforator. 
enabling the operator to open the blades with one 
hand, as in Simpson's instrument. The late Professor Hodge used as a 
perforator a pair of scissors having short blades, the longer of which, 

34 




530 



EMBRYOTOMY 



[CHAP. 



Fig. 182. 



! 



measures an inch and a quarter, and the shorter, one inch. The blades 
are very strong, and the longer one terminates in a triangular sharp 
point, which is used as a perforator when the handles are closed. The 
scissors may be employed to cut up the bones after perforation has been 
effected. — P.] Its mode of application is as follows. The ordinary 
preliminaries to the other operations of midwifery having been carefully 
observed, the woman is to be placed, as usual, upon her left side. Two 
fingers of the left hand are then introduced into the vagina, and brought 
to bear upon the most depending portion of the vault of the cranium. 
With the greatest possible caution, the blades are then to be passed 
along the palmar aspect of these fingers, which serve as a guard to the 

maternal parts, until it reaches the surface 
of the cranium, through which it is thrust 
by a combined pushing and boring move- 
ment as far as the stops. While this is 
being effected, particular attention should 
be given, so that the force be applied at 
right angles to the surface against which it 

OCT O 

impinges, otherwise the point is apt to glance 
off, and may seriously wound the mother. 

Some have advised that perforation should 
be effected at the sutures or fontanclles ; but, 
although this renders the operation some- 
what easier, the disadvantage is that the 
subsequent collapse of the head, by over- 
lapping of the flat bones of which its vault 
is composed, will necessarily obliterate the 
aperture, and impede the escape of the cere- 
bral tissue. It is, therefore, much better 
that we should perforate the parietal bone 
which presents; and, when this has been 
done in the manner described, the handles 
are pressed together and the blades separated. 
This, by tearing asunder the parts, makes a 
lacerated and irregular gap in the cranial 
Avails ; but, in order to render the aperture 
more patent, and thus facilitate the escape 
of the contents, the handles are turned so as 
to bring the blades half round, and another 
similar incision is made at right angles to 
the first. The perforator is then to be thrust 
into the cavity of the cranium, and freely 
moved about in all directions so as to break 
up, as far as is possible, cerebrum, cere- 
bellum, and membranes; and if the child is alive, it will be proper to 
pass it in the direction of the medulla oblongata, so as to cause its 
death, as cases have occurred in which, after perforation and escape of 
the greater portion of the cerebrum, the child has been born alive. The 
perforator is then to be removed with the same precaution as was ob- 




Hodge's craniotomy scissors. 



XXXII.] PERFORATION. 531 

served on its introduction. If the breaking up of the brain has not 
been satisfactorily accomplished, this may be completed by the crotchet, 
which, indeed, some operators prefer altogether for this purpose, with- 
drawing the perforator so soon as the breach in the cranial walls has 
been effected. 

Complete disorganization of the textures within the cranium does 
not necessarily imply their immediate expulsion, which can alone 
insure collapse of the cranial vault. This, no doubt, has already been 
in a great measure effected by the nature of the aperture which we 
have made in the parietal, bone; but, unless uterine action is present, 
and can act efficiently upon the cranium, the amount discharged, even 
through a considerable gap, may be but trifling. In order, therefore, 
to encourage compression, and the consequent diminution of the cranial 
diameters, it has been suggested that we should extract the brain- 
substance; and this may be effected without danger, and with more or 
less of success, — which will be proportionate to the thoroughness with 
which the cerebral disintegration has been effected, — by a scoop or 
spoon, or by the injection within the cranium of a powerful stream of 
water. So soon as a large portion of the cerebral contents has been 
permitted to escape, the bones of the skull will collapse under the in- 
fluence of very trifling compression. This, however, may completely 
fail, whence arises the necessity of proceeding to another stage of the 
operation. 

If nature, after complete decerebration, fails to effect some advance 
of the head, it will then be proper to attempt delivery by traction ex- 
ercised upon any part of it where a secure hold may be maintained. 
The ordinary crotchet, described in a former chapter (see Fig. 174), 
is the instrument which was almost exclusively employed in ancient 
times, and even in the present day is frequently resorted to. The idea 
here is to fix the crotchet upon any part of the bones, and, if possible, 
at the foramen magnum, or the sella turcica, where the best and most 
effective grip may be had, with the least risk of slipping. The direc- 
tions which are very generally given by the older writers for the employ- 
ment of the crotchet after perforation, for the purpose of traction, seem 
to point to fixing it upon some part of the inner surface of the parietal 
bone, and, having thus secured a good hold, to drag steadily down- 
wards. The great objection to the use of the crotchet in this way is 
that it is always unsafe, and, in the hands of the inexperienced, emi- 
nently so. No one uses the crotchet for this purpose, unless he has 
j)reviously passed up the finger of one hand in order to protect the soft 
parts from the possible effects of a sudden and unexpected detachment 
of the instrument, which under other circumstances, would probably 
inflict upon the mother severe, and possibly dangerous laceration. As 
it is often difficult efficiently to protect the parts by means of the 
finger, an instrument called the " guarded crotchet" has been devised. 
It is variously constructed, but consists essentially of two blades, or 
rather of a crotchet and a protecting blade. In that which is shown in 
Fig. 183, the crotchet has three sharp teeth, and is furnished with the 
ordinary forceps joint, by which it is articulated with the protecting 






532 



EMBRYOTOMY. 



[chap. 



blade. The crotchet being introduced within the cranium, is fixed in 
the ordinary manner, and the guard being then passed 
fig^is3. j n f- ne llSLia l wa y outside of the scalp, the instrument is 
locked, which, so long as this relative position is main- 
tained, prevents all possibility of laceration by the sharp 
part of the instrument. 

The danger to the mother is, however, in point of fact, 
less from the crotchet itself, than from the fracture and 
sudden displacement of the bones to which it is attached. 
Should the tractile force be trifling, the hold which the 
crotchet gives us may be maintained ; but if, as is more 
generally the case, we are obliged to use a considerable 
degree of force, the crotchet often slips either from its 
attachment, or by reason of fracture of the bone. It is 
on this account that the guard of the crotchet cannot 
alone be trusted to, and we must therefore pass up the 
finger, which should be retained in apposition with the 
head so long as our efforts may last, so that we may at 
once perceive the earliest indication of slipping, and 
adopt such precautions as may be necessary for the pro- 
tection of the maternal structures. 

The Craniotomy Forceps is, as now constructed, an 
instrument which is greatly superior to the crotchet 
Guarded crotchet, either single or guarded, and is applicable to almost all 
cases in which the latter has been employed. When 
perforation, with evacuation of the cerebral contents, has been com- 
pleted, and it is found necessary to proceed to the further stages of the 
operation, the blades of the craniotomy forceps are to be applied, one 
within and the other without the cranium, that which is convex on 
the outside being for application over the seal]). It will be observed 
that one blade is fitted with sharp teeth corresponding to pits or 
depressions upon the opposed surface of the other. When suitably 
adjusted, therefore, all that the operator has to do is to press the 
handles together with some force, which will insure a grasp upon the 
wall of the cranium, over a more extended area, as well as more firmly, 
than can, under any circumstances, be effected by the crotchet. The 
handles being firmly bound together, traction must now be practiced in 
the direction which may be proper to the actual position of the head. 
If the bone gives way, the detached portions must be cautiously re- 
moved, and a fresh hold obtained wherever the parts may seem most 
likely to bear the strain ; but, when the resistance is great, it will soon 
become evident that this method of extraction will fail, and we must 
therefore pass to a more advanced stage still of the operation of crani- 
otomy. 

The process which, under such circumstances, is rendered necessary, 
is the deliberate removal in detail of the flat bones, which require, for 
this purpose, to be broken up into pieces of convenient size, in order 
that the whole vault of the cranium may be thus removed, including, 
in extreme cases, the occiput and the forehead. No part of the opera- 
tion requires more caution than the removal of the fractured portions 



XXXII.] 



CRANIOTOMY FORCEPS. 



533 



of the bones, which are often jagged and splintered, and always sharp 
at the edges, so much so, sometimes, as to cut through the cuticle of 
the fingers of the operator, which may afterwards be observed to be 
scarred as if by the edge of a sharp knife. When a fragment of bone 
becomes detached, in an attempt at extraction either by the crotchet or 
craniotomy forceps, it is always better to remove it at once, and for 
this purpose the finger will generally suffice. When our object is to 
remove the whole cranial vault, the bones are, in the first place, to be 
broken and separated from their attachments within the scalp — a part 
of the operation which is best effected by means of the craniotomy for- 
ceps. In this case, however, we introduce the blades somewhat differ- 
ently, passing the outer blade between the scalp and the bone, so that 
the latter is directly grasped. A smart wrench by the wrist is generally 
all that is necessary to fracture the bone, when the severed portion 
which remains between the blades may be removed by the aid of the 
instrument. Much will, however, depend upon the shape of the fragment, 
which is to be carefully ascertained by the finger acting in concert with 



Fig. 184. 



Fig. 185. 





Craniotomy forceps. 



Osteotomist. 



the forceps. If it is very irregular in shape, it will, of course, be all 
the more difficult to protect the soft parts of the mother from so many 
cutting surfaces, and it may be necessary to divide it again before 
attempting extraction. The mode of grasping the fragment must also 



534 EMBRYOTOMY. [CHAP. 

be attended to, so as to bring elongated portions lengthwise, and in 
many similar ways we may reduce risk by careful manipulation. Dr. 
Davis was so impressed with the danger which attends the removal of 
the fractured cranial bones that he devised an instrument, or rather a 
series of instruments, which he termed Osteotomists, by which the bones 
could be more safely removed. One of them is shown in Fig. 185. It 
is of the nature of a powerful punch, by which successive minute por- 
tions of the bones may be nipped off and removed in the grasp of the 
blades, thus completely protecting the soft parts. Such an operation 
was necessarily a very tedious one, and this is probably the reason why 
the instrument was never much employed, and has latterly fallen into 
complete disuse. We have, however, found it to be extremely useful 
in cutting any spicule or sharp angular projections which may seem to 
threaten laceration, and for this reason we look upon it as a most useful 
aid to have at hand when we have to perform the operation of crani- 
otomy. By dexterous management, however, we may generally suc- 
ceed in safely removing much larger pieces of bone by the fingers than 
can be effected by the osteotomist. 

[The late Prof. Meigs having had great difficulty in delivering a 
woman with a badly deformed pelvis, though he had at hand the 
various craniotomy instruments, including those of Davis, devised a 
much simpler forceps, one pair with straight, and the other with curved 
blades. We have used these instruments in a number of cases, and 
have found them very efficient in breaking up the cranium, though 
they are not very useful as tractors. 

The best of all craniotomy forceps is Simpson's cranioclast. The 
length of the whole instrument is fourteen inches, and of the blades five 
and a half inches. They are slightly curved. The larger of the two 
blades is fenestrated with grooved sides. The shorter is solid, and 
covered with transverse ridges which fit into the grooves in the opposite 
blade. The two blades are joined by a pivot lock. 

Braun has modified Simpson's instrument by increasing the length 
of both handles and blades, as well as increasing the curvature of the 
latter. Besides these changes he added a compressing apparatus to the 
handles. 

The blades are to be introduced separately, the fenestrated one on 
the outside and the solid one on the inside of the perforated skull. The 
cranioclast is a very efficient instrument, not only as a tractor, but 
likewise to break up the vault of the cranium. — P.] 

In removing the vault of the cranium, it is proper to preserve the 
scalp. The object of this is to protect the maternal parts from injury. 
It may happen, after a certain amount of progress has been made, and 
a considerable portion of the vault removed, that the head collapses to 
such an extent that the difficulty is got over, and extraction becomes 
easy. In such a case the scalp is used as a covering for the bones 
which remain, and as a protection from spiculse and sharp edges, which 
might otherwise do mischief. 

If, at any time in the process of removing the bones, or even earlier, 
we are able to seize the forehead by the craniotomy forceps and pull it 
down, this should always be done; but the difficulty in extreme con- 



XXXII.] 



MEIGS S CRANIOTOMY FORCEPS. 



535 



traction is that the vault of the cranium is not yet sufficiently com- 
pressible. It is mainly, therefore, with the object of ultimately bring- 
ing down the forehead, which usually lies to the right side, that Ave 
thus pick away the bones until there remains, when it is complete, 
nothing but the scalp. 

There is another method of procedure, not often resorted to, but 
which, in some instances, is of undoubted efficiency after perforation. 
This is the ordinary operation of Turning, which may sometimes be 



Fig. 186. 



Fig. 187. 





Meigs's craniotomy forceps. 



Braun's crauioclast. 



effected without much difficulty when, by the perforator, we have 
reduced the bulk of the child's head. To attempt this in cases of very 
great distortion would, on many grounds, be improper ; but in more 
moderate disproportion, it is sometimes an efficient and valuable 
method of completing delivery. A striking instance of this kind, 
which we saw with Drs. Lyon and Dick, was that of a woman in whom 
it had been found necessary to perforate in consequence of very con- 
siderable conjugate contraction. Traction with the craniotomy forceps 
was found to be insufficient, and failed to dislodge the head of the 



536 EMBRYOTOMY. [CHAP. 

child. A considerable portion of the bones was then removed, but, 
before entirely removing them, and proceeding to the more advanced 
stages of the operation, to be described immediately, an attempt was 
made to turn, when, the foot being brought within reach, this was 
effected without the slightest difficulty. In all such cases, it is of the 
first importance that the scalp should cover the fractured bones, and 
we should, therefore, be particularly careful that this should be insured 
before we attempt to turn. 

The flat bones being removed, the next question for consideration 
which presents itself is one which, without a thorough knowledge of 
the foetal and maternal parts, could not fail to give rise to much doubt 
and apprehension. What remains behind of the head consists entirely 
of the base of the cranium, a part which, even at this early age, is very 
solid and unyielding, in order to afford protection to the vital struc- 
tures which might otherwise be subjected to dangerous or fatal pressure. 
The shape of the base of the skull is that of an irregular ovoid disk, the 
long diameters of which are across the pelvis. It would seem, there- 
fore, at first, as if no great advantage had been gained by the removal 
of the flat bones; but a moment's consideration will show that a very 
simple manoeuvre, and one which is generally easy of performance, will 
suffice to place what remains of the head much more favorably. "I 
have carefully," says Dr. Burns, " measured these parts, placed in dif- 
ferent ways, and entirely agree with Dr. Hull, a practitioner of great 
judgment and ability, that the smallest diameter offered, is that which 
extends from the root of the nose to the chin. For, in my experiments, 
after the frontal bones were completely removed, and the lower jaw 
pressed back, or its symphysis divided so as to let its sides be pushed 
away, this did not, in general, exceed an inch and a half. It is, therefore, 
of great advantage to convert the case into a face presentation.' 7 The 
practice thus recommended by Burns was at an earlier date upheld by 
Dr. Osborn, who was the first clearly to show that, by canting the base 
of the skull, so as to bring it edgewise into the brim, it was perfectly 
possible to deliver a full-sized child through a conjugate diameter 
measuring an inch and a half only. A very remarkable case, that of 
Elizabeth Sherwood, was detailed by Dr. Osborn, and has been quoted 
by many subsequent writers. This case, which is specially interesting 
as bearing upon the question which we are now considering, may here 
be advantageously detailed in a very abridged form. 

The patient was so deformed, both in her spine and her lower extremities, " as never 
to be able to stand erect for one minute without the assistance of a crutch under 
each arm." At the age of twenty-seven she became with child, and was admitted 
a patient into Store Street Hospital, where she was seen by W. Hunter, Denham, 
and other eminent obstetricians of the day, who gave their sanction to the course of 
procedure, which Osborn ultimately adopted with such remarkable success. Dr. 
Osborn describes his first examination as follows: "Immediately upon the intro- 
duction of the finger, I perceived a tumor, equal in size, and not very unlike in 
feel, to a child's head. However, it was instantly discovered that this tumor was 
formed by the basis of the sacrum and last lumbar vertebra, which, projecting into 
the cavity at the brim, barely left room for one finger to pass between it and the 
symphysis pubis, so that the space from bone to bone at that part could not exceed 
three-quarters of an i?ich. ,} The operation which was determined upon (a decision 
which gave rise afterwards to no little discussion) was to effect extraction by the 
perforator and crotchet. "Even the first part of the operation, which in general is 



XXXII.] ELIZABETH SHERWOOD'S CASE. 537 

sufficiently easy, was attended with considerable difficulty, and some danger. The 
os uteri was but little dilated, and was awkwardly situated in the centre and most 
contracted part of the brim of the pelvis. The child's head lay loose above the brim, 
and scarcely within reach of the finger, nor was there any suture directly opposite 
to the os uteri." The operation of perforation and decerebration was effected with- 
out any unusual difficulty, and the patient was then left, as was the general practice 
in those days, for six-and-thirty hours, in order to allow the uterus opportunity to 
force the cranium downwards as far as possible within the reach of the crotchet, a 
result which was counted upon to some extent, as the effect of putrefactive change. 

" I determined," he continues, " to begin to make an attempt to extract the child. 
I call it an attempt, for I was far from being satisfied in my own mind of the practica- 
bility. My first endeavors were bent to draw the os uteri with my finger into the 
widest part of the brim of the pelvis, and to dilate it as much as possible. But the 
removal of the os uteri, and such dilatation of it as the bones admitted, were effected 
without much trouble. I then introduced the crotchet through the perforation into 
the head, and, by repeated efforts, made in the slowest and most cautious manner, 
destroyed almost the whole of the parietal and frontal bones, or the whole upper 
presenting part of the head, and as the bones became loose and detached, they were 
extracted with a pair of strong forceps, to prevent, as much as possible, laceration 
of the vagina in their passage through it. The great bulk of the head, formed by 
the base of the skull, still, however, remained above the brim of the pelvis; and 
from the manner in which it lay, it was impossible to enter without either diminish- 
ing the volume, or changing the position: the former was the most obvious method, 
for it was a continuation of the same process, and I trusted, would be equally easy 
in execution. I was, however, grievous^ mistaken and disappointed, being re- 
peatedly foiled in every endeavor to break the solid bones which form the basis of 
the cranium, the instrument at first invariably slipping as often and as soon as it 
was fixed, or, at least, before I could exert sufficient force to break the bone. At last, 
however, by changing the position of the instrument, and applying the convex side 
to the pubis, I fixed the point, I believe, into the great foramen, and by that means 
became master of the most powerful purchase that the nature of the case admitted. 

" Of this I availed myself to the utmost extent; slowly, gradually, but steadily 
increasing my force till it arrived at that degree of violence which nothing could 
justify but the extreme necessity of the case and the absolute inability, in repeated 
trials, of succeeding by gentler means. But even this force was to no purpose, for 
I could not perceive that I had made any impression on that solid bone, or that it 
had been in the least advanced by all my exertions. I became fearful of renewing 
the same force in the same way, and therefore abandoned altogether the first idea of 
breaking the basis of the cranium, and determined to try the second by endeavoring 
to change the position. I therefore again introduced the crotchet in the same 
manner, and fixing it in the great foramen, got possession of my former purchase ; 
then, introducing two fingers of the left hand, I endeavored with them to raise one 
side of the forepart of the head, and turn it a little edgeways. Immediately and 
easily succeeding in this attempt, the two great objects were at once accomplished ; 
for the position was changed and the volume diminished. Continuing my exer- 
tions with the crotchet, I soon perceived the head advance, and, examining again, 
found a considerable portion of it had been brought into the pelvis. Every diffi- 
culty was now removed, and, by a perseverance in the same means for a short time, 
the remaining part of the head was brought down and out of the os externum." 

We cannot wonder that the result in this case, and the satisfactory 
recovery of the mother, should have been looked upon as a great 
triumph of the crotchet as compared with the otherwise inevitable ex-, 
pedient of the Caesarian Section. Of late years this question has been 
more thoroughly investigated and illustrated. Dr. Braxton Hicks, in 
a learned and elaborate paper, 1 describes very fully the mechanism of 
the proceeding. What he recommends is to grapple the orbit and 
draw it downwards by means of a small blunt hook. " The one 
which I use," he says, " is of the following size : the diameter of the 
iron rod from which it is made is about a quarter of an inch, of the 

1 Obstetrical Transactions, vol. vi, 1865, p. 263. 



538 EMBRYOTOMY. [CHAP. 

length of the ordinary blunt hook ; with handle also alike. The hook 
is a half circle, about one inch in diameter, and is made hard, to pre- 
vent its opening during traction ; the shaft is made of soft iron, and 
can be bent by the hand into any form, being thus adaptable to any 
situation. I may mention here that this hook is useful, in other cases, 
in a variety of ways, where it is impossible to employ the unwieldy 
blunt hook in general use." 

Dr. Barnes, after removing the arch of the calvarinm, or the whole 
of the bones if the distortion be extreme, prefers, for effecting the same 
object, the craniotomy forceps. The instrument which he uses is of 
considerable strength, and is provided with a screw at the ends of the 
handles, which secures for it the ordinary advantages of the cephalo- 
tribe, by crushing in the frontal bones, and has the further advantage 
of securing an unyielding hold. " Then traction is made, carefully 
backwards at first, in the course of the circle round the false promontory. 
As the face descends it tends to turn chin forwards, and this turn may 
be promoted by turning the handles of the instrument. It is not nec- 
essary that the turn should take place, for the case differs entirely from 
that of the normal head. There is no occiput to roll back upon the 
spine between the shoulders. The head conies through flatwise like 
a disk by its edge." 

The above extracts, which represent the most modern and scientific 
modes of practice, will suffice to show that where the pelvis measures 
two inches, or even a little less, in the conjugate diameter, a fully de- 
veloped child may yet possibly be extracted. It is obvious, however, — 
the transverse diameter of the face being more considerable, — that, to 
insure success, there must be a larger space, certainly not less than three 
inches in the transverse diameter. "I go further," says Barnes, in 
reference to this operation, " and declare that it is perfectly unjustifiable 
to neglect this proceeding, and to cast the woman's life upon the slender 
chance afforded by the Caesarian Section." 

The Cephalotribe. — If the facts and arguments above cited are strictly 
correct, the number of cases in which the cephalotribe is called for are 
probably very limited in number. They are certainly much more so 
than was at one time supposed. The earliest instrument designed for 
crushing: the bones of the foetal skull seems to have been the Com- 
pressor Forceps of Assolini, which was used by him to crush the base 
of the skull and the face, early in the present century. The blades of 
this instrument were not made to cross, so that when they were screwed 
together, the fulcrum of each lever was the joint at the end of the han- 
dles, where they were articulated. The only modern instrument re- 
sembling this in principle is the cephalotribe of Lazarewitch of Char- 
koff. What, with certain modifications, is known as the French 
cephalotribe, was invented by the younger Baudelocque. It is, in 
appearance, a most formidable instrument; the one in our possession 
weighing no less than 4 lbs. 6J oz., and measuring across the blades 
nearly two inches, in the widest part. It requires, therefore, no argu- 
ment to show that such an apparatus is not applicable to a case like 
-that of Elizabeth Sherwood. Various modifications have, in modern 
times, been designed by Scanzoni, Braun, Simpson, and others, almost 



xxxn.] 



THE CEPHALOTRIBE. 



539 



all of which are constructed with a moderate degree of pelvic curve. 
They are all made lighter than the original instrument, as it has been 
found that clumsiness may be, to some extent, avoided without any 
material sacrifice of strength. The tendency of the English instru- 
ments is to approach more in form to the ordinary midwifery forceps, 
as is well shown in Simpson's cephalotribe, which is here represented. 



Fig. 189. 



Fig. 190. 



Fig. 188. 




Simpson's cephalotribe. 




French cephalotribe. Dr. Matthews Duncan's cephalotribe. 



As in the case of the forceps, there has existed in this country some 
controversy as to whether the pelvic curve should or should not be 
adapted to the cephalotribe, those who approve a£ the straight instru- 
ment arguing with some force that the straight blades are easier of 
application, and can alone be properly applied when we wish to rotate. 
The fact that the head is at the brim seems to us, on the contrary, to 
vindicate, on the same grounds which have been urged with reference 
to the long forceps, that unless we are, as Pajot and some others advise, 
absolutely to discard the instrument as an extractor, we must admit 
that the principle of the pelvic curve must be conceded here also. The 
objections which Dr. Kidd and others have urged against the pelvic 



540 EMBRYOTOMY. [CHAP. 

curve have, however, so far prevailed that the English instruments are 
all, without exception, made with a slighter curve than the French 
ones. The French cephalotribes still retain, as we have said (and, we 
may add also, the German modifications of Braun and Scanzoni), much 
of the original formidable dimensions of the instrument. We might 
have contented ourselves with the mere mention of this fact were it not 
that of late years some able obstetricians have condemned the English 
instrument, and insisted that we should do better to adhere more 
closely to French models in the construction of cephalotribes. Dr. Mat- 
thews Duncan, assisted by Professor Inglis of Aberdeen, and others, made 
some very interesting experiments with a view of comparing the effects 
of Simpson's cephalotribe and the more modern of the French instru- 
ments. The experiments were performed on foetal crania, and on the 
skulls of dogs, and certainly served very clearly to demonstrate that 
the French cephalotribes have greater power. Are we, therefore, on 
that account, to prefer them, to the exclusion of those with shorter 
handles? 

In reply to this question, Dr. Duncan expresses a decided preference 
for the French cephalotribe, a modification of which he has devised, so 
as to combine the lesser degree of pelvic curve which is characteristic 
of English instruments, with certain other modifications which he con- 
siders as offering some advantage. Dr. Duncan's cephalotribe is repre- 
sented in Fig. 190. Drs. Barnes and Braxton Hicks are again warm 
supporters of what we have termed the English cephalotribe, and while 
they do not assert that the crushing force is equal to that of the French 
instrument, they maintain that the power is attained in sufficient per- 
fection for the object which we have in view, and that there is a gain 
in the facility of handling, which may be held as sufficient to counter- 
balance any trifling loss of power. 

We have at present to consider the subject of Cephalotripsy as the 
final stage of the operation of craniotomy in cases of great pelvic con- 
traction. Perforation, decerebration, removal of the flat bones, and 
canting edgewise of the base of the skull, have all, Ave shall suppose, 
been successively tried, but to no purpose. Can anything further, we 
ask ourselves, be done in this same direction? — a question which finds 
its reply in the operation which we are now considering. The object 
of the instrument is, as its name implies, to crush the unyielding base 
into a pulp, and thus bring it through the contracted diameters. The 
blades are introduced, in the same manner as those of the ordinary long 
forceps, in the direction in which there is least resistance, which will 
generally be the sides of the pelvis. They are passed high up, so as to 
reach quite beyond the base, which it is our object to crush ; and, being 
adjusted, the screw is then turned steadily and cautiously, while the 
finger within the vagina takes note of what is being done, and is ready 
to remove at once any spicule of bone which may crop up under the 
influence of the crushing force. Whatever form of instrument we may 
choose, it should be one which does not measure, when closed, more 
than an inch and a half outside the widest part of the blades. This 
admits, therefore, of such crushing as may enable the head to pass 
through a diameter which may be contracted to that extent. If the 



XXXII.] THE CEPHALOTRIBE. 541 

deformity is great, a second crushing may be necessary, and for this 
purpose, the blades should be removed and reintroduced, so as to se- 
cure a grasp which should be, as nearly as possible, at right angles to 
the first. 

It must not be supposed that it is only to cases in which the whole 
of the flat bones have been already removed that the operation of 
cephalotripsy is applicable. On the contrary, it may often be used 
with advantage when only a portion of the vault has been got away. 
This is generally sufficient to admit of the easy introduction of the 
blades, so that, if unusual difficulty is experienced in extracting the 
bones, and the head refuses to advance under steady traction, the 
operation will have the double effect of crushing the base and per- 
mitting the collapse of the skull, and complete escape of all its contents. 
In this case, however, we should watch with special caution the effect 
of the compression upon the cranium, otherwise the maternal parts 
may, at any moment, be wounded by fragments of the tabular bones. 

[The author ascribes powers to the cephalotribe which are hardly 
warranted by the experience of others. The base of the skull is frac- 
tured with great difficulty by this instrument. Von Weber experi- 
mented on the heads of dead children, and found that though the base 
may be broken, fractures are less common than simple bending of the 
bones inward, or the turning of the base upon its axis. Hicks made 
the same statement in 1870, and in a subsequent paper added that, 
" the reduction ... of the base is a matter of great difficulty, and 
requires great power in the instrument." Barnes believes that it may 
be made to partly crush the base, and evidently takes what is a correct 
view of the powers of the cephalotribe, — that it is useful rather to break 
up the perforated cranium than to decompose the base. Hicks appre- 
ciates the full extent of the powers of the instrument, when he asserts 
that it is intended to crush the cranium so that the base may be turned 
and brought through the contracted brim edgewise. — P.] 

A subject, which has given rise to no little discussion, is whether or 
not we should, after crushing, use the cephalotribe as a tractor. Pajot 
condemns such a course, and recommends a procedure which he de- 
scribes as " cephalotripsie repetee sans tractions" in which he leaves ex- 
pulsion absolutely to nature. He also recommends, what, if feasible, 
is certainly advantageous, — that we should rotate the head which has 
been operated upon, so as to bring its crushed diameter in relation 
with the contracted diameter of the pelvis. This condemnation of the 
cephalotribe as a tractor, seems chiefly to be supported by those who, 
in France or elsewhere, uphold the use of the bulky instruments which 
are very obviously less suitable for such a purpose. What seems, there- 
fore, to be the chief advantage of the lighter English instrument, is that 
traction may by it be more safely performed. Indeed, it appears to us 
in the highest degree irrational that we should forego all the advantages 
of traction which spring from such a firm grasp of the head as the 
cephalotribe gives. Caution, indeed, we can scarcely exaggerate ; but, 
we can see no reason why, after efficient crushing, we should not pull 
gently with the handles backwards, which we can, of course, do with 
more safety, and at greater advantage, than if there was no pelvic 



542 EMBRYOTOMY. [CIIAP. 

curve to the blades. Another disadvantage of removing the blades, 
and leaving the further progress of the case to nature is said by Dr. 
Barnes to consist in the resiliency of the foetal structures ; so that a 
head flattened within the grasp of the cephalotribe so as to measure 
not more than an inch and a half, may spring out on the removal of 
the blades to more than two inches. 

When the mutilated head at length glides through the chink which 
has so obstinately barred its progress, the young operator may hastily 
conclude that his operative difficulties are necessarily at an end. In 
cases of minor disproportion, it will no doubt be so ; but, in extreme 
distortion, the descent of the shoulders and trunk may be attended with 
very considerable difficulty. If the remains of the head be still within 
the grasp of the cephalotribe, it is proper to continue the tractile force 
backwards, as far as may be practicable with a due regard to the in- 
tegrity of the perineal structures. This is done with the view of disen- 
gaging the anterior shoulder, or bringing it a little in advance, so that 
the blunt hook may be fixed in the axilla to pull it through. It may 
be necessary at this stage, when the blunt hook and crotchet fail to 
effect delivery, that the cephalotribe should be again used, and the 
trunk crushed prior to delivery ; a proceeding which, although rarely 
necessary, is certainly preferable to the employment of such violence 
as might otherwise endanger the tissues of the mother. 

There are cases in which it is found necessary to lessen the bulk of 
the head in breech presentations, or after turning, the head being 
arrested after the trunk has been successfully disengaged from a con- 
tracted pelvis. In this case, the conditions of the operation are in- 
verted, but are not by any means, as a rule, more difficult. Perforation 
may be effected behind the ear, and this situation should be selected 
as the point at which we may most readily attain the cavity of the 
cranium, and give exit to the brain-substance, so as to permit of the 
collapse of the head. In this case, also, the cephalotribe may be em- 
ployed with great advantage, by crushing the base of the skull, which 
in this instance is in advance of the vault; and, if the measurements 
are such as to have already admitted of turning, or of the descent of 
the breech, we may be almost sure that the collapse of the head which 
must now necessarily ensue, will amply suffice to permit of its passage 
through the pelvis. 

Embryulcia. — When some part of the child other than the head 
presents, it may be necessary to use the perforator upon the trunk, 
and endeavor to extract the child by the evacuation of the contents of 
the thorax and abdomen. This is one of the methods, for example, 
which have been practiced in cases of transverse presentation in which 
turning is impracticable. There is no difficulty in such a case in making 
a breach in the thoracic walls, below the axilla, of sufficient size to 
admit of the removal of the lungs and heart, and, subsequently, by 
perforation of the diaphragm, of the abdominal viscera — the most im- 
portant of these being the liver, which, as is well known, is of great 
size in the foetus. The breaking up of the organs prior to their removal 
cannot be effected in the same bold manner as in craniotomy, as we 
might easily perforate the trunk, and wound the walls of the uterus. 



XXXII.] EMBRYULCIA. 543 

After thus reducing the bulk of the trunk, what should now be 
attempted is an imitation of the natural processes of spontaneous evo- 
lution, or spontaneous expulsion, which may be effected by forcibly 
dragging down the breech, by the blunt hook or otherwise, after the 
organs have been removed. This, however, is not always easy ; and 
we have a vivid recollection of such a case, which we saw many years 
ago, where turning had been found impracticable, and embryulcia had 
been practiced to the extent of removing the whole of the abdominal 
and thoracic organs. The crotchet and blunt hook were repeatedly 
fixed upon the pelvis and lower vertebras, but without success, and the 
woman ultimately died undelivered. Looking back upon this case 
with the vividness with which memory recalls early experiences, we 
feel assured that the treatment proper to it ought to have been decapi- 
tation, and not evisceration. 

The former operation lias been described in a previous chapter, and 
should, we believe, be always taken into consideration when the 
question of embryulcia in impacted transverse presentation crops up. 
Evisceration is not, however, limited to cases of transverse presenta- 
tion, but may be found necessary, and has often been practiced as a 
sequel of craniotomy, when it may be requisite to diminish the bulk of 
the trunk, on precisely the same principle as has guided us to perfora- 
tion of the cranium at an earlier stage of the operation, where we 
cannot succeed in delivering by the blunt hook, crotchet, or any other 
instrument which we may employ purely for the purpose of traction. 
It is probable, however, that under such circumstances, the process 
previously detailed, in which the cephalotribe is the agent employed, 
might be adopted with a better prospect of satisfactory results. 

A very powerful instrument, but one rather complicated in its con- 
struction, is that which was invented by Van Huevel, of Brussels, and 
has subsequently been adopted by some eminent Continental prac- 
titioners as a substitute for the crotchet, cephalotribe, and other instru- 
ments, which we have described as essential to the performance of 
craniotomy, under any circumstances which may involve greater diffi- 
culty than usual. This instrument is known as Van HuevePs Forceps 
Saw, and consists in the first place of forceps, of which the blades are 
of unusual strength. On the inner aspect of the latter is a groove 
extending from about one inch below the extremity to near the lock. 
Within the groove, and protected by a band of steel, the chain saw is 
introduced after the blades have been adjusted, and is then made to 
cut from without inwards, or from the lock towards the tips of the 
blades, until the head has been divided, — the chain being worked by 
two small cross handles at its extremities, while its action, protected by 
the blades of the forceps, may be looked upon as absolutely safe. 

Dr. Barnes has lately suggested another operation, by which the wire 
ecraseur may be used for the purpose of bisecting the head, or other- 
wise operating upon the body of the foetus. This method of performing 
Embryotomy was demonstrated by the inventor before the Obstetrical 
Society, the instrument employed being the ecraseur of Braxton Hicks. 
He recommends the employment, not of the wire rope suggested by 



544 EMBRYOTOMY. [CHAP. 

Hicks, 1 but of a single loop of strong steel wire, which he manipulates, 
so as to pass it through the cervix uteri and the chink of the pelvic 
brim. The crotchet being passed into the hole made by the perforator, 
and held by an assistant, so as to steady the head, the loop is guided 
over the crotchet to the right side of the uterus, where the face lies. 
u The compression being removed, the loop springs open to form its 
original ring, which is guided over the anterior part of the head. The 
screw is then tightened. Instantly the wire is buried in the scalp; 
and here is manifested a singular advantage of this operation. The 
whole force of the necessary manoeuvres is expended on the foetus. 
In the ordinary modes of performing embryotomy, as by the crotchet 
especially, and in a lesser degree by the craniotomy forceps and omphal- 
otribe, the mother's soft parts are subjected to pressure and contusion. 
The child's head, imperfectly reduced in bulk, is forcibly dragged down 
upon the narrow pelvis, the intervening soft parts being liable to be 
bruised, crushed, and even perforated. And this danger, obviously in- 
creasing in proportion to the extent of the pelvic contraction, together 
with the bulk of the instruments used, deprives the mother, in all cases 
of extreme contraction, of the benefit of embryotomy, leaving her only 
the terrible prospect of the Caesarian section. When the anterior or 
posterior segment of the head is seized in the wire loop, a steady work- 
ing of the screw cuts through the head in a few minutes. The loose 
segment is then removed by the craniotomy forceps. In minor degrees 
of contraction, the removal of one segment is enough to enable the rest 
of the head to be extracted by the craniotomy forceps. But in the 
class of extreme cases, in which this operation is especially useful, it is 
desirable still further to reduce the head, by taking off another section. 
This is best done by reapplving the loop over the occipital end of the 
head." 

A word may here be added as to the probable range of cases within 
which the cephalotribe may be applied. Much will, of course, depend, 
as has already been observed, upon the degree of contraction, not only 
of the conjugate, but of the other diameters of the pelvis. In a discus- 
sion on this subject, held at Berlin, the majority of the speakers thought 
that a minimum of two inches in the conjugate diameter was necessary. 
Crede, Pajot, Hicks, and Barnes have however encountered cases in 
which the contraction ranged from one and three-quarters to one and 
a half inches, and have yet been able successfully to accomplish the 
operation. It is important that facts such as these should be borne in 
mind when we have to consider the dernier ressort of operative mid- 
wifery, — the Caesarian Section, — which will form the subject of the fol- 
lowing chapter. 

1 We have frequently employed this instrument for the removal of uterine polypi, 
and in other similar operations, but have found that the wire ropes suggested by the 
inventor are not to be depended upon, and are apt to snap under a powerful strain. 
Thinking at first that this was due either to some imperfection of the instrument, or 
to some fault in the annealing of the wire of which the rope was composed, we con- 
sulted Dr. Hicks, who was so obliging as to order a complete instrument and ropes, 
after his own model ; but the result was still far from satisfactory. From the expe- 
rience we have since had of the single steel wire suggested by Dr. Barnes, we are 
inclined to give to it a decided preference. 



XXXIII.] HYSTEROTOMY. 545 






CHAPTER XXXIII. 

HYSTEROTOMY AND ALLIED OPERATIONS. 

HISTORY OF THE OPERATION OP HYSTEROTOMY — CASES IN WHICH IT IS JUSTIFIABLE : 
MATERNAL MORTALITY: DIFFERENT RESULTS IN BRITISH AND CONTINENTAL 
PRACTICE — CONDITIONS FAVORABLE TO SUCCESS — THE OPERATION ASD ITS 

details: duties of the assistants: closure of THE WOUNDS — AFTER- 
TREATMENT— CAUSES OF FATAL RESULT — EFFECT OF COLD IN PREVENTING 
PERITONITIS — REPEATED SUCCESS OF THE OPERATION IN THE SAME CASES — 
GASTROTOMY : CASES IN WHICH THE OPERATION IS REQUIRED — THE SO-CALLED 
VAGINAL CAESARIAN SECTION — SYMPHYSIOTOMY: HISTORY AND NATURE OF 
THIS OPERATION: OBJECTIONS TO IT — STOLTZ'S OPERATION OF PUBIOTOMY — 
TABULAR STATEMENT SHOWING THE DEGREE OF CONJUGATE CONTRACTION AT 
THE BRIM, WHICH MAY BE SUPPOSED TO INDICATE RESPECTIVELY THE OPERA- 
TIONS OF THE LONG FORCEPS, TURNING, EMBRYOTOMY, AND THE CESARIAN 
SECTION. 

Hysterotomy, Laparo-Hysterotorny, or, as it is more familiarly 
known, the Caesarian Section, is an operation whereby the foetus is 
extracted through an opening which is made in the abdominal and 
uterine walls. The propriety of such a procedure, in the case of the 
sudden death of the mother, is, in the hope of extracting a living child, 
so obviously a course to which no exception can be taken, that nothing 
need be urged in justification of the operation in the abstract. 

From the earliest period in the history of midwifery, it had been 
occasionally practiced on women dying during labor; and the names 
of Scipio Africanus, Manilius, Andrea Doria, and others, are recorded 
as having been brought into the world under such circumstances, in 
obedience to the law of Numa, which forbade the burial of a pregnant 
woman in whom the operation had not been performed. About the 
end of the sixteenth or the beginning of the seventeenth century, it 
would appear that the operation had been performed in cases in which 
the child had escaped into the cavity of the peritoneum ; but as this 
proceeding is not, properly speaking, the Caesarian Section, these cases 
are only to be regarded as instances of Laparotomy or Gastrotomy. It 
is not precisely known at what epoch Hysterotomy was first performed 
on the living woman ; for there is every reason to believe that the cases 
published by Rousset in 1581 were to be referred chiefly to the pre- 
ceding category. This work, celebrated in the history of the subject, 
gave rise to the most extravagant expectations, and at one time the 
operation was so recklessly performed by surgeons, that it was only by 
the uncompromising attitude of Guillemeau and Ambroise Pare that it 
fell into disfavor. It is of this period that Scipio Merunia spoke when 
he talked, with pardonable exaggeration, of the operation being as 

35 



546 HYSTEROTOMY. [CHAP. 

common in France as bleeding in Italy. The opposition thus encoun- 
tered in such influential quarters had well-nigh condemned the Caesarian 
operation to oblivion ; but it was again revived, and gave rise to endless 
and bitter discussion during the whole of the seventeenth, and, we may 
add, the first half of the last century, without anything definite having 
been elicited or determined upon, the profession being divided into two 
parties, one of which condemned the operation in the most uncom- 
promising way, while the other as warmly, and with even less of dis- 
cretion, was enthusiastic in its support. It will be observed, therefore, 
that the Caesarian Section, as now calmly looked upon in the light of 
science, dates from quite modern times. 

While it must be admitted that every step in advance which has been 
established by conservative midwifery throws further into the shade the 
sacrificial or more desperate operative resources of the art, there proba- 
bly exist no practitioners in the present day who will not admit that 
there are cases in which hysterotomy is justifiable on grounds which 
will stand the test of the strictest scientific examination. Putting aside, 
for the moment, the cases in which it may be practiced upon the dead, 
it may be broadly asserted that the operation is called for on the living 
in all cases in which the state of parts is such as to preclude the possi- 
bility of delivery by embryotomy. In other words, we arc driven to 
this last resource wherever we recognize the fact, that the foetus, how- 
ever mutilated, cannot be extracted by the pelvic canal. 

Considerable difference of opinion unfortunately exists as to the limit 
of contraction which will warrant the performance of Hysterotomy. In 
Germany it is very generally asserted that two and a half inches, in 
the conjugate of the brim, is to be held as the limit in question; but 
there are, in so far as we are aware, none in this country who indorse 
this view. What has already been said in the preceding chapter affords 
ample proof that Craniotomy may be successfully performed in con- 
tractions of one inch and three-quarters; and the experience of some of 
the most distinguished of modern operators seems to show that this 
limit may be reduced to one inch and a half. We may say, then, con- 
fidently, that when the conjugate diameter exceeds these limits, we are 
in no case justified in at once deciding in favor of the Caesarian opera- 
tion. We must once more, however, reiterate a former observation, and 
call attention to the fact that the conjugate measurement is not alone to 
betaken into account — as it is too much the fashion to do — seeing that 
we may have irregular or angular distortion, in which the other diame- 
ters are similarly or, it may be, chiefly distorted. And it is a point of 
very great interest and importance that, of the whole number of re- 
ported cases of hysterotomy, a large majority were due to osteomalacia, 
in which, as we have seen, the typical distortion does not involve the 
conjugate diameter at all. A much smaller number were cases of 
rickets ; and, among the rarer conditions calling for the operation, may 
be mentioned exostosis, fracture of the pelvis, spondylolisthesis, fibrous 
or other tumors, and carcinoma of the os and cervix. What we wish, 
therefore, more particularly to notice is that the conjugate measurement 
cannot be accepted as the test of the necessity which may be assumed to 
exist for the performance of this operation. 









XXXIII.] HYSTEROTOMY. 547 

The maternal mortality in this country has been so great — not less 
than 85 per cent, of all recorded cases — that a very general idea prevails 
that this is almost exclusively a child's operation. This is a double 
error ; for, when we perform the operation, in a case where we know that 
the child cannot be otherwise born, we give the mother the chance, small 
though it be, of recovering from the effects of the operation, while 
otherwise we must leave her to die; and, as regards the child, the re- 
sults are far from being so favorable as to warrant us in looking upon 
it as a child's operation, although it may, no doubt, fairly be inferred 
that this is attributable in some degree to the fact that the operation is 
often delayed too long. 

If we turn for a moment from British to Continental statistics, it 
must be admitted that the results are vastly more favorable in the 
latter case. The reason of this is obvious, and has its origin directly 
or indirectly in the greater regard for foetal life, which, on religious 
grounds, causes hysterotomy to be looked upon with more favor than 
embryotomy. Dubois says, for example, that when the brim is con- 
tracted to two inches, and the child is living, we should choose the 
former operation without hesitation. His authority, therefore, and that 
of others of equal distinction, has necessarily led to the performance of 
hysterotomy in a larger proportion of cases than has ever obtained in 
this country. Moreover, the very anxiety to save the child leads to the 
performance of the operation at a much earlier period of labor than is 
practiced in this country ; and we cannot doubt that if is this which 
brings about their successful results. [Dr. Robert P. Harris, of Phila- 
delphia, has carefully investigated the history of the Caesarian operation 
in the United States, and has published the results of his study in the 
fourth volume of the American Journal of Obstetrics. Of 60 women 
operated on in this country, 32 recovered and 28 died, a mortality of 
46.66 per cent. Of the children, 27 were saved. Dr. Harris says 
that " if we calculate the risks of gastro-hysterotomy in this country 
from the cases operated on in cities and large towns, or by their sur- 
geons in their immediate vicinity, giving them all the advantages that 
skill and service can command, we find that sixty per cent, of the women 
recovered." At the close of his second paper, he appends a tabular 
statement of the results of seventeen operations " performed during 
or at the close of the first day of labor." Of these women 73 J § per 
cent, survived, while 86 f$ per cent, of the children were saved. It is, 
therefore, not unreasonable to expect that in the future the results of 
this operation will equal those of ovariotomy. — P.] It is, indeed, of vital 
importance that the operation should not be delayed until symptoms of 
exhaustion have set in, as has been too often the case in England, — 
although we operate, primarily at least, in the interests of the mother, 
and with a mere secondary consideration for the life of the child. It 
is difficult to avoid the conclusion — in which we have the support of 
Cazeaux — that the operation is rashly undertaken, by many of our Con- 
tinental brethren, in cases where the proper operation is embryotomy. 
This is one of many causes which should encourage us to give to the 
subject of embryotomy our best and most earnest consideration, that we 
may, by perfecting that operation, reduce more and more the necessity 



548 HYSTEROTOMY. [CHAP. 

for having recourse to hysterotomy. If we admit the religious element 
into the question, or other considerations, such as that suggested by 
Denman — that we should gravely consider, whether, in the case of a 
woman who, knowing that she cannot bear a living child, has allowed 
herself to become pregnant, we should not act rather in the interests of 
the child ; or, in other words, if we weigh the life of the child as of 
equal importance in any case with that of the mother, we will speedily 
become bewildered in the mazes of casuistry, and may be led to do 
what is morally wrong. In a word, hysterotomy is no exception to 
the general rule that we should act primarily in the interests of the 
mother. 

When the operation is called for by the death of the mother, either 
before or during labor, there are no considerations which will encourage 
a moment's hesitation or delay. During labor, it may be possible to 
turn and deliver, or to extract by the forceps almost as rapidly as to 
remove the child through the abdominal walls — and this proceeding 
has the advantage of being less repugnant to the feelings of relatives 
and friends ; but, if the os is not sufficiently dilated, or if labor has not 
commenced, we have no choice in the matter, the only rule being to 
extract the child without unnecessary delay. The period during which 
the vitality of the child may be preserved is probably very limited. 
Authentic cases are recorded in which the child has been removed alive 
ten, fifteen, and even thirty minutes after the death of the mother ; but 
we must treat as fables those instances of which we read, where it is 
said to have been found alive ten, fifteen, or twenty-four hours after 
the mother had ceased to live. In death before the seventh month, it 
would be a manifest impropriety to operate ; but religious convictions 
have caused this to be done in order that the child may have the 
benefit of Christian baptism. 

The Caesarian operation is, however, under certain circumstances, 
imperatively demanded while the mother still lives. Let us see, there- 
fore, what are the conditions upon which success will mainly depend. 
The first, and perhaps the most important point, is the early recogni- 
tion of the nature and extent of the obstruction. This will enable us 
to prepare the woman, in some degree, for the great peril to which she 
is about to be subjected, by careful attention to the bowels and so forth. 
It is a matter of doubt, whether we should wait for the coming on of 
labor, or induce it artificially. There are arguments in favor of both 
modes of procedure, but perhaps the safest plan will be to wait until 
nature gives evidence that she is about to call upon the uterus to assume 
its physiological action, which will be an assistance to the operator at 
certain stages ; and, besides, we are entitled to assume that, at the full 
time, the healing process is more likely to be encouraged by the normal 
physiological phenomena of involution. Under no circumstances should 
we operate until the os has opened to some extent, so as to permit of 
the discharges passing by the normal channel ; but, if it be thought 
advisable to precipitate matters, this can always be done by some of 
the ordinary modes of procedure for bringing on premature labor. 
Winckel says that the most favorable period for the operation is the 
end of the first stage ; and he recommends that we should not rupture 



XXXIII.] 



THE OPERATION. 



549 



the membranes, as some have done, with the view of permitting the 
escape of the liquor amnii. 

The Operation. — The measures to be taken before commencing the 
operation should be those which the most experienced of our ovarioto- 
mists have found, of late years, to be conducive .to success. The 
patient should be placed upon a high bed or table, in a good light, 
with her shoulders a little elevated. The temperature of the room 
should, if necessary, be artificially raised. There should be at hand 
an abundant supply of hot and cold water, and a weak solution of 
carbolic acid, with a sufficiency of towels and sponges. Several bis- 
touries, with sharp and blunt points, artery forceps, ligatures of various 
kinds (including antiseptic catgut), bandages, carbolized dressings, and 
a long probang, will, with the usual minor instruments of an ordinary 
pocket-case, be all that is necessary. The propriety of giving chloro- 
form in this operation has been called in question, chiefly on account 
of the disastrous effect which an attack of retching might have at a 



Fig. 191. 




Hysterotomy. 



critical moment of the procedure ; but, if the stomach is empty before 
this agent is administered, the risk is not likely to be great. The 
operator, standing in front of the patient, and having ascertained that 
the bladder is empty, must first examine the abdominal walls, in order 
to ascertain, with precision, the position of the uterus with reference 
to them. A final examination, per vaginam, should also be made, as 
some cases of osteomalacia have been recorded in which the bones of 



550 HYSTEROTOMY. [CHAP. 

an extremely distorted pelvis have yielded so much as to admit of the 
passage of the hand. The primary incision is to be made in the middle 
line, and should extend from a little below the umbilicus to about two 
and a half inches above the pubic symphysis. Further than this it 
would be imprudent to go in the latter direction, and, in the case of 
extreme deformity or unusual shortness of stature rendering a larger 
incision necessary than can be effected by this rule, the wound should 
be commenced above, and a little to the left of the umbilicus. The 
knife should be carried through the skin and subcutaneous cellular 
tissue, and the various aponeurotic layers successively divided, until 
the peritoneum is reached. Any bleeding vessels should be carefully 
secured before going further. 

The uterus having been previously adjusted, so as to bring its axis as 
nearly as may be into parallelism with the abdominal incision, the 
hands of two assistants are now to be placed above and below, with the 
view of bringing the uterine and abdominal walls into close apposition, 
and thus maintaining their relative positions until the operation has 
been completed. The section of the peritoneum should be effected with 
caution, not only with the view of protecting the subjacent uterine tissue, 
but also to avert the possibility of wounding the bow r el, as cases have 
been known in which convolutions of the small intestines were lodged 
in front of the uterus. When the peritoneal cavity has been opened 
in this manner, the operator should introduce, through the first minute 
incision, a director, upon which he may cut ; or having made an aper- 
ture sufficient to admit of the passage of the forefinger, that may be ad- 
vantageously used as a director, along the palmar surface of which a 
blunt-pointed bistoury may be passed. During the whole of this pro- 
cess, the attention of the assistants should be sustained, so as to prevent 
the possibility of protrusion of the bowels, while any discharge should 
be assiduously removed by means of sponges wrung out of carbolic 
solution. 

The surface of the uterus being now brought into view, the next 
stage of the operation consists in the section of its walls. It has been 
said that the site of the placenta may be determined by auscultation, a 
bulging of that portion of the uterine wall, and by certain other signs 
to which it is unnecessary to refer ; but we do not believe that any of 
these signs are such as may be depended upon, so that the exact situa- 
tion of the placenta must remain, in some degree at least, doubtful. 
The uterine incision is to be made in the middle line, so as to corre- 
spond to that in the abdominal walls, and is to be carried cautiously 
through the peritoneum and proper tissue of the organ, so as to avoid 
the fundus and cervix ; the reason being that the section of the circular 
fibres there situated would be extremely likely to cause a gaping of 
the wound. As the knife approaches the inner surface of the uterus, 
we must exercise some caution lest we injure the placenta, which may 
be immediately subjacent ; and if it should chance that this structure 
intervenes between us and the embryo, we must carefully make our 
way to the edge of the placenta before attempting to extract the child. 

If — as is usually considered a favorable condition at this stage — the 
membranes are intact, the escape of the liquor amnii must be guarded 



XXXIII.] THE UTERINE INCISION. 551 

against at the moment of perforation. For this purpose, the aperture in 
the membranes should be made as minute as possible, and an assistant 
specially detailed for this duty should carefully receive in sponges the 
fluid as it escapes, so as to prevent its entrance into the cavity of the 
peritoneum. An orifice of sufficient size being thereupon made, the 
extraction of the child is to be effected with the least possible delay, 
the feet being seized, and delivery promptly completed. While this is 
being done, a certain amount of uterine contraction will usually occur, 
which is an additional reason for speedy action on our part ; otherwise, 
the breach in the uterine walls will become rapidly diminished in size. 
It has not unfrequently happened that, when the body of the child has 
been successfully extracted, the contraction has been so rapid as to cause 
the neck to be so firmly grasped as to prevent the completion of the 
operation, a state of matters in which it is better to enlarge the incision, 
than to use force, by Avhich we can only succeed by tearing open the 
wound. 

If the placenta is not at once detached, the hand should be immedi- 
ately introduced into the cavity, and the organ separated from its at- 
tachments, and extracted as the hand is being withdrawn. The chief 
risk of the operation at this stage is, of course, the haemorrhage which 
necessarily occurs from the uterine sinuses which have been cut through, 
as well as from the inner surface of that portion of the orgaji from 
which the placenta has been separated. The former is the source from 
which bleeding is chiefly to be looked for ; but experience has shown 
that this risk is very much less than might have been anticipated, the 
actual amount of discharge depending, in a great measure, on the effi- 
ciency of the uterine contractions ; and it is certain that, fatal as the 
operation is in its results, death rarely ensues from haemorrhage. The 
greatest care on the part of the assistants is necessary, in order to pre- 
vent the entrance of the blood and other discharges into the cavity of 
the peritoneum, and the escape from it of the intestines. Perfect success 
in this direction is, of course, impracticable; but we may be sure that 
the less the quantity of such discharges that comes in contact with the 
peritoneal membrane, the less likely is the dreaded peritonitis to be 
severe or fatal in its character. The use of the carbolic solution, by 
sponges and otherwise, will further reduce this risk. The escape of the 
intestines may be prevented, and the approximation of the uterine and 
abdominal walls efficiently maintained, by an expedient which was sug- 
gested by Winckel. This consists in having the extremities of the 
uterine wound hooked upwards by the finger, and thus brought into 
contact with the walls of the abdomen, a manoeuvre which is peculiarly 
applicable to cases in which the number of assistants is deficient. The 
probang should finally be passed downwards through the os uteri to 
the vagina, which insures for the discharges free egress by the normal 
channel. 

Delivery having been by these means effected, the mode of closure 
and general management of the incisions, uterine and abdominal, is the 
subject which next engages our attention. When the uterus has well 
contracted, — a process which is materially hastened by pressure of the 
organ, and even by the application of cold, — when all bleeding has 



552 HYSTEROTOMY. [CHAP. 

ceased, and when the discharges have been wiped away as thoroughly 
as possible, the edges of the wounds are to be brought into apposition. 
It is a matter of dispute whether we should or should not stitch the 
uterine wound. It is quite certain that this is not essential to success, 
and it is doubtful, as may be inferred from the experience of Winckel, 
whether or not it is in any way beneficial. Still, on ordinary surgical 
principles, and recognizing the fact that, in a certain number of fatal 
cases, the wound has been found gaping after death, we cannot wonder 
that most operators seek in this way to promote union of the uterine 
tissues. But for one circumstance, the most advantageous procedure 
would be to bring the uterine and abdominal wounds into close apposi- 
tion by the same suture ; but the circumstance in question is a most im- 
portant one, and depends upon the contractility and natural involution 
of the uterine tissue, which would probably involve forcible dragging 
upon the wound. To effect closure of the uterine incision by means of 
suture, while the risk referred to is at the same time avoided, has been, 
therefore, the great object of many of those who have had occasion to 
perform the operation. Mr. Spencer Wells, for example, in a case in 
which he performed it with a successful result, passed an uninterrupted 
silk suture, the end of which he brought through the vagina, and subse- 
quently removed ; while Dr. Barnes suggests an ingenious but more 
complicated method, by which the uterus is stitched and united to the 
margin of the abdominal wound, while provision is, at the same time, 
made for the contraction above referred to. 

Whether or not the uterine wound is stitched, that in the abdominal 
wall is, of course, to be carefully closed by suture. The material to 
which a preference is usually given is fine silver wire, of which five or 
six stitches are to be passed through the cutaneous and peritoneal 
margins of the incision ; and after these have been carefully adjusted, 
they are to be drawn tight and fastened in the usual way, additional 
superficial sutures being, if necessary, added, so as to bring the whole 
length of the superficial incision into accurate apposition. The carbol- 
ized catgut ligatures suggested by Professor Lister may, with possible 
advantage, be substituted for the silver wire. Prepared gauze or other 
antiseptic dressings may now be applied, and are to be retained in their 
position by strips of sticking-plaster and a carefully adjusted bandage. 

A full opiate should now be administered either by enema or other 
suppository, and perfect quiet and rest enjoined, the dressings being 
undisturbed for five or six days. The sutures are to be removed about 
the eighth day. The vagina may be washed out by injections of tepid 
water with a little Condy's fluid, and the bladder emptied by means of 
the catheter twice a day; and on the fourth or fifth day, the bowels 
may be relieved by a simple enema. The diet throughout should be 
of the lightest possible character, and every conceivable disturbing 
element, bodily or mental, should be scrupulously avoided. 

Reference has already been made to the operation of ovariotomy. It 
must not, however, be supposed that we have any idea of tracing the 
analogy which exists between the two operations. Hysterotomy, in- 
deed, involves conditions which are manifestly far less favorable than 
those which attend on an ordinary case of ovariotomy, and we need not 



XXXIII.] CAUSES OF FATAL RESULT. 553 

wonder that the results are less successful. We cannot, however, avoid 
the reflection, that not many years ago the latter operation was looked 
upon as scarcely more promising in its results than that which we are 
now considering; and, when we reflect further upon the wonderful 
improvements which modern surgical skill has effected in the one 
operation, we are surely justified in expressing a hope that the expe- 
rience thus gained may be so made available as materially to reduce, 
in the future, the fearful mortality which, in the past, has attended the 
Caesarian Section. Upon nothing will the result be more likely to de- 
pend than upon the period at which the operation is performed. If, 
as has too generally been the case in this country, it is adopted only as 
a last resource, when the vital powers are exhausted by lingering labor, 
the expedient is, indeed, a desperate one. But if, on the contrary, the 
necessity is recognized at a period sufficiently early to enable us to 
select the time and the conditions which are most favorable, our prog- 
nosis will admit of something more of hope. 

The shock of the operation is often very great, and may prove fatal 
at once, before the secondary effects of peritoneal inflammation have 
manifested themselves. Haemorrhage is, as we have said, and as the 
experience of Winckel has shown, by no means a prominent cause of 
the fatal result; but it is otherwise with peritonitis, which may be 
looked upon as almost inevitable when the woman survives the imme- 
diate effects of the operation. This may come on within twenty-four 
hours, and is indicated by the occurrence of rigor, severe abdominal 
pain, with more or less tenderness on pressure, labored respiration, 
flatulent distension of the bowels, and a rapid, wiry pulse. These 
alarming symptoms may be combated by fomentations or poultices to 
the abdomen, mild salines, and opium ; but, unfortunately, in the great 
majority of cases, the symptoms will go on unchecked until, under 
their influence, the patient succumbs. Metz, of Aix-la-Chapelle, in- 
sists upon the importance of the sustained use of cold in averting peri- 
toneal inflammation. The rash employment of this agent would, un- 
doubtedly, as every one knows, rather tend, by reaction, to produce 
inflammation than to repress it; but of this Metz was quite aware. 
He recommends that, so soon as the woman has been put to bed after 
the operation, compresses of cold water should be placed over the ab- 
domen, and that, after a few hours, ice in a bladder should be sub- 
stituted, while cold injections are thrown into the rectum, and the 
patient is encouraged to swallow, from time to time, morsels of ice. 
Under such treatment, he says, the patient is sensible of a feeling of 
comfort to which she was previously a stranger, and this sensation may 
be fully trusted to as a safe guide to the length of time, and the extent 
to which this mode of treatment may be safely carried. So long, then, 
as the woman remains comfortable, cold may be employed ; but the 
moment she complains of chill or discomfort, the cold is at once to be 
modified or withdrawn. Cazeaux seems to give a general support to 
this mode of treatment, which has also been practiced by Kilian. Dr. 
Metz asserts, that of thirteen cases treated on this principle one only 
died, — a statement so glaringly absurd, that we can only suppose this 
is one of the many pernicious instances of the reckless use of statistics 



554 HYSTEROTOMY. [CHAP. 

with which, unfortunately, the literature of obstetrics is disfigured, and 
which sometimes makes us incline to pass by with contempt sugges- 
tions which may, nevertheless, have in them the germ of truth and 
practical worth. 

It sometimes happens, as a result of the healing process, that the 
uterine and abdominal wounds become agglutinated, so as to produce 
permanent adhesion at this place, without, as would appear, entailing 
any serious inconvenience. This fact is made use of by those who 
advocate the stitching together of the two wounds, and there has been 
proved to exist, in some of those cases in which the Caesarian Section 
has been repeatedly performed, an extent of adhesion which has ad- 
mitted of the performance of the operation without opening the peri- 
toneal cavity ; and it is obviously to this fact that the exceptional suc- 
cess attendant on such operations is to be attributed. 

[In 1870, Prof. T. G. Thomas, of New York, proposed to revive the 
operation of Gastro-Elytrotomy as a substitute for the Caesarian Sec- 
tion. As a preliminary to this operation, the os uteri is to be dilated 
sufficiently to allow version to be performed. This being done, an 
incision is made with a bistoury in the iliac fossa, the cut extending 
from the spine of the pubis to the anterior superior spine of the ilium, 
along the line of Poupart's ligament. The abdominal muscles being 
divided, the peritoneum is to be separated from its attachments, until 
the vagino-uterine junction is reached. A steel sound should now be 
passed into the vagina, and the walls of that canal made tense, so that 
they can be incised, the sound serving as a director. This done, the 
os is pulled into the iliac fossa by a blunt hook, the fundus being tilted 
in the opposite direction. By this means the operator is enabled to 
pass his hand into the uterus, seize the feet, and extract the child 
through the opening in the abdominal walls. Dr. Thomas has suc- 
ceeded in extracting a living child in this manner in one instance on a 
dying woman. Dr. Skene has since operated, but the merits of this 
method of delivery in a narrow pelvis are not yet determined. The 
immediate dangers are haemorrhage and shock, the more remote, cellu- 
litis and septicaemia. How great the danger from haemorrhage may be, 
experience alone can determine. — P.] 

Gastrotomy , or Laparotomy, is an operation which has already been 
alluded to as applicable to cases in which the child has escaped into 
the abdominal cavity, either from a ruptured uterus, or in cases of 
extra-uterine pregnancy. Some of the older cases which have been 
recorded as Caesarian Section have clearly been of this nature, — the 
operation being, as is obvious, only one stage of the more formidable 
procedure which we have been considering. There may, possibly, be 
cases, moreover, as has already been shown, in which, although the 
cyst of an extra-uterine conception has not been ruptured, it is neces- 
sary to perform this operation when the life of the mother is threatened 
by pressure on important organs, and also under some other circum- 
stances of a like nature. 

The operation is simply the first stage of the Caesarian Section, and 
it is to be conducted with precisely the same precautions ; but an aper- 
ture must be left at the lower part of the external wound, to permit of 



XXXIII.] GASTROTOMY — SYMPHYSIOTOMY. 555 

the escape of the discharges. It might naturally be inferred that an 
operation which does not involve the uterine walls, would be attended 
with much more favorable results. In practice, however, we shall 
probably, when we take the whole circumstances into consideration, 
look upon the one with as great apprehension as the other. The 
operation of Gastrotomy has, in fact, certain special dangers in the 
practice of midwifery, and is very different, in all respects, from the 
ordinary operation for the removal of an ovarian cyst. The conditions 
which attend rupture of the uterus, or of an extra-uterine cyst, have 
already been detailed, when those accidents were under consideration. 
In each case, the ovum, its appendages, and the liquor in which it floats, 
all escape into the peritoneal cavity, along with a large quantity of 
fluid and clotted blood, — a portion of which must necessarily be left 
behind, — so that the chances of peritonitis are probably not less in the 
one case than in the other. And, in the case of extra-uterine preg- 
nancy, the peculiar anatomical conditions which are often involved 
in the nature of the placental attachment, are of such a nature as to 
render these cases specially hazardous. In fact, whatever statistics 
may seem to prove, and Kilian and a few others may have said, we 
must always look upon this operation as one of the last resources of 
our art. 

When the child is extracted by means of incision, practiced from 
the vagina, the operation has by some been termed Vaginal Caesarian 
Section, a phrase which is obviously improper. The circumstances 
which may render necessary such an operation as this, are malignant 
disease of the os and cervix, congenital occlusion of the os, or retrover- 
sion of a gravid uterus. Similar operations, not involving the tissues 
of the uterus, may be practiced in some rare instances of extra-uterine 
pregnancy, in which the foetus may be reached in this way; but, in all 
these cases, the operation is simple, and requires no special directions 
other than to use bistouries and other instruments so guarded as to 
incur no risk of wounding the surrounding tissues ; and, at the same 
time, to cut with care, so as to avoid inflicting any injury upon the 
child. 

Symphysiotomy. — In 1768, Sigault, a young student of medicine, at 
Paris, submitted to the Academie de Chirurgie, a proposition that 
women might be delivered without very great risk, by means of an 
operation which he thus named. The proposal was received with 
ridicule, and the essayist was treated as a madman. Nothing daunted, 
however, by this rebuff, the young Sigault stoutly maintained his posi- 
tion for several years, but it was not until 1777 that he performed his 
first operation in the presence, and with the assistance of the celebrated 
Leroy, who, having espoused his cause, ultimately became a warm 
advocate of the new procedure. Both mother and child were saved in 
this case, and Sigault soon found himself famous and overwhelmed with 
benefits, as the discoverer of a method which was to replace the hated 
Csesarian Section, and, consequently, as a benefactor of his race. The 
Academie de Medecine, as if to atone for the indignity which the sister 
society had put upon him, received him with open arms, and actually 
struck a medal in honor of the event. In France and Germany, the 



556 SYMPHYSIOTOMY. [CHAP. 

profession was much divided on the subject, but in England it somehow 
never gained a footing, nor would we even now have given any atten- 
tion to the matter, were it not that, in all modern Continental works 
on obstetrics, some degree of prominence is still given to the operation, 
as one which might, under certain circumstances, be advantageously 
performed. 

The division of the pubic symphysis is, from a surgical point of view, 
a matter so simple, that it is unnecessary to particularize the details. 
It is proper, however, that in expressing as we now do the opinion that 
the operation is one which must be unhesitatingly and absolutely re- 
jected as irrational, some reason should be adduced for a view which 
is so confidently expressed. To begin, then, symphysiotomy is to be 
rejected as a mere chimerical idea, which had its origin in views as to 
the movement of the pelvic bones during labor, than which nothing, 
theoretically or practically, could be more incorrect. It was shown, in 
an early chapter of this work, that the very trifling movement w T hich 
nature permits during labor in the human pelvis is one in which the 
symphysis pubis is the hinge. At the time when Sigault wrote, the 
idea usually entertained was exactly the opposite — viz., that the hinge 
w r as at the sacro-iliac synchondrosis, and that the pelvis gaped at the 
symphysis ; and it could only, of course, have been with the object of 
encouraging such a movement as this, that the operation could on 
rational grounds be supported. Again, such an obstruction as might 
seem to call either for Craniotomy, the Caesarian Section, or this new 
operation, would, in a considerable majority of all cases, consist mainly 
in contraction of the conjugate diameter of the brim ; but a moment's 
reflection will serve to show that this operation is not one which is 
likely to increase the diameter thus encroached upon, for, while it 
certainly will augment the circumferential measurement of the pelvis, 
and the transverse and oblique diameters, it leaves the conjugate com- 
paratively untouched. And, if we turn to the results of the operation, 
we will at once find that the boasted advantage has no existence, save 
in the imagination of the inventor. Baudelocque says that, in forty- 
one cases of the operation, fourteen women died, while only thirteen 
children were born alive. The narrative of recorded cases shows that, 
while the forces of nature may prevail after the operation, it will often 
be found necessary to apply the forceps, or turn, after the original 
operation has been completed. As regards ultimate results, Cazeaux 
says, " In the most fortunate cases, the consolidation of the symphysis 
is only complete after a lapse of three or four months. Women have 
been seen in whom it had never taken place, and who, nevertheless, 
have eventually been able to walk. There then forms, according to 
Alphonse Leroy, a fibro-cellular tissue which, filling up the gap in the 
symphysis, maintains the solidity of the articulation." 

Various modifications of the operation have been suggested, including 
one method which has received the support of Stoltz, of Strasburg, 
and which he termed Pubiotomy. In this case the operation is per- 
formed by a chain saw, which is introduced subcutaneously. A small 
opening is first made to the right or left of the middle line over the 
pelvic crest, and through this a strong needle, slightly curved, is intro- 



XXXIII.] PUBIOTOMY. 557 

duced. This is passed behind the pubis, and brought out by the side 
of the clitoris, and by it the chain saw, to which it has previously been 
attached, is pulled through, and made to act upon the body of the pubis 
from within outwards, until the bone has been divided. The operation 
of symphysiotomy has been but once practiced, in so far as we are aware, 
in this country ; and on the Continent, in the present day, it is so 
seldom employed that the question may now be looked upon as forming 
little more than an episode in the history of the operative midwifery of 
the past. 

It may be interesting at this place, by way of recapitulation — but 
without any pretence of, or attempt at anything more than an approxi- 
mation at accuracy — to set down, in a tabular form, the various con- 
jugate measurements at the brim which, according to the best authori- 
ties, may be supposed to indicate the necessity for the several operations 
which we have now been considering. Burns, speaking of one of the 
operations referred to, says, — and the observation will apply with equal 
force to any of them, — " There is only one degree of disproportion, then, 
betwixt the head and the pelvis which will admit of this ; but the 
smallest deviation from it destroys the advantage of the operation. 
Now, as this disproportion is so nice, we cannot in practice ascertain it; 
for, although we could determine, within a hundredth part of an 
inch, the capacity of the pelvis, yet we cannot determine the precise 
dimensions of the head, and thus establish the relation of the two." 
The student, we would again repeat, — at the risk of being accused of 
unnecessary iteration, — must, above all things, beware of assuming 
that conjugate contraction is his only guide, or one which is uniformly 
to be relied upon. The following figures, therefore, have reference 
only to cases of conjugate contraction, in which the other diameters are 
either unaltered, or are, at least, not very greatly diminished. With 
reference, more particularly, to the Caesarian Section, in which osteo- 
malacia is the most frequent cause of deformity, it should be remem- 
bered that, in that type of pelvis, the conjugate measurement, so far 
from being a criterion of the deformity, is more likely to lead the 
observer to conclusions which are quite erroneous. 

With this explanation, then, the following may be given, as showing, 
according to the most approved authorities, the degree of conjugate con- 
traction at the brim, which may be supposed, under ordinary circum- 
stances, to indicate the various operations which have been described : 

Long forceps, 4 to 3£ inches. 

Turning, 3£ to 2f " 

Craniotomy, . . . . . . 3 to l| " 

Caesarian Section, . . . . . 1£ and under. 



558 INDUCTION OF PREMATURE LABOR. [CHAP. 



CHAPTER XXXIV. 

INDUCTION OF PREMATURE LABOR. 

HISTORY OF THE SUBJECT — NATURE AND SCOPE OF THE OPERATION — VIABILITY, 
OR NON-VIABILITY OF THE CHILD — CONDITIONS WHICH JUSTIFY THE OPERA- 
TION — VARIOUS METHODS OF PROVOKING UTERINE ACTTON : ERGOT: PUNCTUR- 
ING THE MEMBRANES: SEPARATION OF THE MEMBRANES BY HAMILTON'S 
METHOD: DILATATION OF THE CERVIX BY TENTS: INTRODUCTION OF AN 
ELASTIC BOUGIE OR CATHETER INTO THE UTERUS: PLUGGING OR DISTENDING 
THE VAGINA: THE METHOD OF KIWISCH BY THE VAGINAL DOUCHE : COHEN'S 
METHOD BY INTRA-UTERINE INJECTIONS: DR BARNES'S PROCESS, CONSISTING 
OF A "PROVOCATIVE" AND AN " ACCELERATIVE " STAGE: GALVANISM: 
IRRITATION OF THE BREASTS — ANATOMICAL AND PHYSIOLOGICAL FITNESS OF 
THE PARTS— CONSTITUTIONAL INFLUENCES. 

It is with something of a sense of relief that we torn from a con- 
sideration of the destructive operations of midwifery, to what is perhaps, 
in the strictest and truest sense, the most conservative of all the re- 
sources of our art. There is a fitness, moreover, in considering the 
subject at this place, as it affords, within certain limits, a means by 
which the necessity for the more serious operations may be avoided. 

Of all methods of operative procedure which are applicable to the 
practice of obstetrics, there is none which has given rise to such pro- 
longed and often acrimonious discussion. Putting aside various ex- 
pedients which were occasionally adopted both in ancient and modern 
times to expedite delivery, there can be no doubt that the induction 
of premature labor is an operation which we owe to the sound judg- 
ment of the English school of midwifery, by the sheer force of which, 
and the vigorous support it received from many influential quarters, 
the operation was soon forced into notice. In 1556, a conference was 
held in London, which was attended by the most eminent practitioners 
of the day, at which this question was fully and exhaustively considered 
in all its bearings, with the result of formally admitting it as a recognized 
practice of the English School. 

For reasons which have already been more than once adverted to, 
the induction of premature labor was not likely to obtain a ready 
assent on the Continent, where, on the contrary, it found opponents 
who were so virulent in their hostility, that an operation, which is per- 
haps above all others morally right as well as beneficent in its action, 
was for many long years contemptuously rejected. The great force of 
truth, however, ultimately prevailed, and the operation was performed 
in Germany by Wenzel in 1804; but it was not till 1831 that Stoltz 
of Strasburg led the way by performing the first operation in France — 
not the least of the benefits which this distinguished obstetrician con- 



XXXIV.] CONDITIONS WHICH JUSTIFY THE OPERATION. 559 

ferred upon that branch of science with which his name is still honora- 
bly connected. From this moment, the success of the operation was 
assured, even in the country where it had been longest resisted. Sen- 
timental scruples in regard to foetal life, which had swayed the opinion 
of many, were shown to be in this case quite irrational, and could be 
supported by no argument, moral or religious ; the sophistry of which 
could not easily be expressed. As time wore on, all doubt vanished, 
and it may now be said that in the present day, the practice of the 
Continent is as advanced as it is in England, and perhaps of late years 
the operation has attracted even more attention than with us. The 
only remnant of the original prejudice, which still exists in the minds 
of some, is the opinion, occasionally entertained, that we should not 
perform the operation repeatedly upon the same woman, on the prin- 
ciple which has induced these persons to bring the interests of the child 
into greater prominence in the case of a woman who has once been 
delivered by craniotomy, and who ought, therefore, according to them, 
to be exposed to the fearful danger of the Caesarian Section, in order 
that the infant may be born alive. 

The induction of Premature Labor, in its widest sense, is an opera- 
tion varying greatly in its details, whereby the uterus is artificially 
stimulated to expel its contents at any period prior to the completion 
of the full term of utero-gestation. The merest glance at the subject 
will therefore suffice to show that the operator must feel the sense of 
responsibility more, the earlier the period of pregnancy at which the 
presumed necessity for the operation may arise. At the sixth, and at 
the ninth month, the operation will differ in no essential particular, and 
may be attended with equally trifling risk to the mother. But, in the 
one case, we sacrifice a child, by bringing it into the world before it is 
viable ; while, in the other, we merely induce the premature expulsion 
of an infant which there is every reason to suppose may survive; so 
that, we must carefully draw a distinction between the induction of 
abortion, and of premature labor in its more restricted sense. The 
general opinion, which has found expression in the " Code Napoleon," 
is, that the end of the sixth month is the period at which the foetus 
may be considered viable ; but the experience of all accoucheurs extends 
this till towards the end of the seventh month — before which time, in- 
deed, w r e have but little hope that the child may be reared. It is clear, 
therefore, that if the cause calling for the induction of premature labor 
is of such a nature as to warrant us in deferring the operation until the 
end of the seventh month has been reached, we should do so, avoiding, 
at the same time, the risk of over-caution, which, by delaying too long, 
may leave the mother exposed to the dangers from which it is our 
primary object to save her. 

The conditions under which we may be justified in performing the 
operation vary considerably. When we operate before the middle of 
the seventh month, we may look upon our procedure as one which we 
undertake in the interests of the mother alone, without any reference 
to the child, which is thus deliberately sacrificed. While it is true 
that these are the cases in which a sense of responsibility is most likely 
to weigh upon us, there are instances, undoubtedly, in which delay 



560 INDUCTION OF PREMATURE LABOR. [CHAP. 

incurs a responsibility more serious still, in leaving the case to nature, 
when the sole alternative of the Caesarian Section will almost surely 
result in the sacrifice of the mother, and probably also of the child. 
There is another class of cases, — which have been alluded to in a pre- 
vious chapter, — in which we are sometimes, though very rarely, war- 
ranted in inducing abortion. The most familiar example of this is 
found in the excessive vomiting which occasionally attends pregnancy, 
so as to bring women previously healthy to the very verge of dissolu- 
tion. We have great difficulty in admitting this as a cause justifying 
abortion, and most certainly no young practitioner should have recourse 
to the operation, without very careful consideration, and, if possible, 
the advice and assistance of those more experienced than himself. 
For, if disaster does occur, — and we cannot doubt, from cases given by 
Tyler Smith and others, that it occasionally does so, — from delay, we 
cannot but fear that a too great familiarity, under such circumstances, 
with an operation which is in itself simple enough, would result in a 
wanton sacrifice of foetal life. Nature, as we have already shown, 
almost invariably comes to the relief of such cases, so that the circum- 
stances which might warrant the operation must be extremely rare. 

There are instances, again, in which, at a more advanced period of 
pregnancy, the operation is undertaken in the interests of the child. 
There are few practitioners of much experience, who have not encoun- 
tered cases in which women, often apparently robust, have been, on 
successive occasions, delivered of stillborn children near the full time. 
In such, we should not hesitate to bring on labor before the time at 
which the death of the foetus was presumed to have occurred in former 
pregnancies, fixing the period as near the natural termination of the 
pregnancy as may be deemed prudent. The causes which give rise to 
the death of the foetus, in these cases, are often obscure, and sometimes 
can by no means be distinguished ; but in most instances there is, as we 
may assume from what has actually been demonstrated, some diseased 
condition, which interrupts the placental circulation, and thus causes 
the death of the child. Any of the diseased conditions of the placenta 
formerly enumerated, — such, for example, as fatty degeneration, — may 
have this effect ; and it is, probably, when the disease is rapidly pro- 
gressive, towards the end of pregnancy, that we are able, by premature 
delivery, to avert its otherwise inevitable effect on the life of the child, 
by placing the latter in circumstances in which, aerial respiration hav- 
ing been established, it is independent of the placental circulation. 

It is, as we have seen, a natural physiological accompaniment of 
pregnancy, towards its termination, that the utero-placeutal tissues 
loosen somewhat, preparatory to the occurrence of delivery; and, when 
no actual disease of the placenta can be discovered, it has been sup- 
posed that premature separation of the decidua may, either by rupture 
of the vessels, or by interference with the circulation within them, 
directly or indirectly destroy the foetus. In some cases, — of which we 
have seen two examples, — it would seem as if the uterus, as in habitual 
abortion independent of disease, had assumed a habit of throwing off 
its contents at a certain time, before the conditions otherwise favorable 
to live-birth were in operation ; and yet, when this so-called habit is 



XXXIV.] CONDITIONS WHICH JUSTIFY THE OPERATION. 561 

once broken by the induction of premature labor at a somewhat earlier 
period, the woman, in subsequent pregnancies, carries her children to 
the full time. The operation may even be warranted in cases in which, 
although the children may have previously been born alive, they have, 
owing to the occurrence of some of the diseases referred to, been the 
subjects of what has been termed, with some propriety, " intra-uterine 
marasmus/' and have not long survived their birth. In cases of still- 
birth, a very excellent rule which has been laid down for our guidance 
in subsequent pregnancies is to examine with great care the placenta 
and membranes. 

The cases which are most frequent in their occurrence, and, at the 
same time, most satisfactory in their results, are those in which we 
operate with the double object of saving both mother and child from 
great peril or almost certain death. Merriman has insisted, with great 
justice, upon the caution which w T e should exercise, when the conditions 
which seem to indicate the necessity for premature delivery occur in 
primiparce. To a great extent, this warning is sound and judicious, 
but we must avoid carrying the principle too far; for, if the circum- 
stances are such as seem to preclude the possibility of the passage of a 
mature foetus at the full term, we are equally justified, in primiparae, 
as in other cases, in having recourse to an operation which thus obviates 
inevitable risk. In pluripara?, much, and possibly everything, will 
depend upon the history of former labors. If, for example, it has been 
found necessary once or oftener, to relieve the woman in previous 
labors by the operation of craniotomy, or even by turning or the long 
forceps, with an invariably fatal result, the estimate which we may be 
inclined to form of the probable danger is thus corroborated by expe- 
rience ; but, where the indications are less certain, we must be firmly 
convinced that the operation gives the best chance to the child as well 
as to the mother, before we can hold ourselves as warranted in acting. 

Inasmuch as the life of the infant will depend, in all cases, upon the 
degree of development which has been attained prior to birth, it is of 
the first importance that we should form a correct estimate of the period 
beyond which we cannot safely go. As the necessity for this proceed- 
ing, as well as for the more serious expedients of embryotomy and the 
Caesarian Section, arises, in a very large proportion of cases, from con- 
traction of the conjugate diameter of the brim, we should, in the first 
place, endeavor to ascertain, with as much accuracy as may be attain- 
able, the precise degree of the contraction. This may be done approxi- 
mately by the methods of pelvimetry which have been already detailed. 
It is obvious that such an amount of contraction as would call for the 
Caesarian operation, will require measures for the relief of the woman 
to be taken at an earlier period than when the diameters are such as to 
point to embryotomy. In cases of conjugate contraction, as has already 
been shown, the head lies pretty nearly in the transverse diameter, so 
that it is the biparietal measurement which corresponds to the con- 
tracted diameter of the brim. 

While estimating, therefore, the degree of pelvic contraction, it is 
proper that we, at the same time, bear in mind the probable measure- 
ments of the biparietal diameter of the cranium at various epochs in 



562 INDUCTION OF PREMATURE LABOR. [CHAP. 

the course of the last two or three months of pregnancy. Stoltz has 
ventured to give measurements which, reduced to the standard of the 
English inch, we may quote as probably approximating the actual con- 
dition of the parts. Between the thirty-second and the thirty-third 
week, the biparietal diameter is somewhere about two inches and three- 
quarters ; from the thirty-fourth to the thirty-fifth, three inches ; and 
from the thirty-sixth to the thirty-seventh, three inches and one-third. 
If, therefore, we have to deal with a case in which the conjugate 
diameter is two inches and a half, or under, we should operate not 
later than the end of the seventh month, even making all allowance for 
the greater compressibility of which the head, at this early period, is 
susceptible. Conclusive proof of twin pregnancy may, as Cazeaux 
has shown, modify our procedure in this particular, or might even 
warrant us in abandoning the case to nature, if the contraction is not 
excessive; and this for two reasons, — because twins are generally less 
developed, and because their organization is seldom so perfect when 
they are prematurely born as to enable them to maintain an indepen- 
dent existence. 

In cases of pelvic distortion where the conjugate falls under one inch 
and three-quarters, the only possible alternative will, in most cases, be 
the Caesarian Section. A case such as this necessitates abortion, for it 
is only by operating in the course of the sixth month at latest, that we 
can expect to save our patient, by the expulsion of the foetus before the 
period of viability. At whatever period the operation may be resolved 
upon, there is always a greater probability, which should not be lost 
sight of, of obstruction from malposition of the foetus ; and the more 
removed the case is from the natural term of gestation, the more likely 
is this to occur, and to constitute a practical difficulty which may not 
have been anticipated. It must not be supposed that pelvic contrac- 
tions are the sole conditions, in addition to such as have previously 
ibeen mentioned, which lead to the operation we are now considering. 
We have already seen that, in certain cases of hemorrhage, w T hether 
accidental or unavoidable, the only course of procedure that we can 
adopt is one which, by inciting the uterus to premature contraction, 
relieves the mother from the state of peril into which she has fallen, 
and at the same time may be the means of preserving the child. 

But, in addition to these, which clearly point to the operation, there 
are many other instances which may fairly be admitted to stand in a 
more doubtful category. When a woman, for example, is, towards the 
end of pregnancy, affected by a serious disorder, which apparently 
places her life in immediate jeopardy, it cannot fail to be a matter of 
anxious consideration whether or not we are to reject the operative 
means which we have at our command, which will generally save the 
child, and may often save the mother. Here, as in all other cases, we 
must place the interests of the mother before those of the child. It 
will not be a safe rule in practice, although it may seem so in theory, 
that we may operate to save the child, if we are persuaded that, by so 
doing, we shall not augment the danger of the mother ; so that we 
should, in such cases, operate only when we can convince ourselves that 



XXXIV.] CONDITIONS WHICH JUSTIFY THE OPERATION. 563 

the procedure is also, in the main, one which affords the mother the 
best chance of her life. 

Cases of this kind, under a variety of forms, occasionally occur in 
practice. In dropsical effusions into the great cavities, to such an ex- 
tent as to interfere seriously- with the function of respiration, no pro- 
found consideration is required to show that distension of the uterus is 
an element or unit in the mechanical causes which place the woman's 
life in peril ; and it is, at least, a reasonable assumption that, by sub- 
tracting this unit from the sum-total of unfavorable conditions, we 
give the mother an additional chance, while we withdraw the child 
from the operation of causes which may materially imperil its exist- 
ence. Certain cases of cardiac disease, or of aneurismal tumors, in 
which the pressure of the gravid uterus seems likely to precipitate a 
catastrophe which we may regard as ultimately inevitable, may, on 
similar principles, be our warrant in inducing a premature expulsion 
of the uterine contents ; but, in the course of practice, other exigencies 
may offer themselves, in which, while the indications are less clear, we 
may yet consider ourselves justified in bringing the pregnancy to an 
abrupt termination. 

Several years ago, we had an opportunity of seeing a case of this 
kind in consultation with Dr. Dobbie, of Ayr. The patient was a lady 
aged thirty, who had been for some years the subject of chronic asthma. 
She was in the eighth month of her fourth pregnancy, laboring under 
severe chronic bronchitis, of a cyanotic appearance, and with an ex- 
tremely feeble and irregular pulse. All the ordinary means, applied 
with much skill and discrimination, had failed to afford any relief, and 
it was therefore resolved, in the apparently desperate circumstances of 
the case, to have recourse to the induction of premature labor. Dr. 
Dobbie kindly supplied me afterwards with the following details of the 
issue of the case : " About eight o'clock on Friday evening I made a 
vaginal examination, with a view to learn the exact position of things, 
and, in doing so, I found the tissues all so lax and moist, and the 
uterus reaching so low in the pelvis, — almost touching the perineum, — 
that, without withdrawing my hand, I commenced dilating the os, 
first with my forefinger, and then with the fore and middle fingers. 
At the end of half an hour, and without any complaint of pain on the 
patient's part, the os was fully the size of a crown, and I left it. Pains 
had slightly commenced by this time, and they went on increasing, 
but, throughout the labor, they were of a very moderate kind. At 
10.45 p.m. labor was terminated by the birth of a living and healthy 
female child. We did our best to support strength by stimulating 
freely ; but without avail. She died at 5 A.M on Saturday." 

This is a tolerably good illustration of the exceptional cases referred 
to. The result, as regards the mother, was only what might have been 
anticipated, had the symptoms detailed been observed unconnected 
with the pregnant state ; and, if the case had been abandoned to the 
operation of nature, we cannot doubt that the result would have been 
a dead child as well as a dead mother. Furthermore, a retrospect of 
the case does not now modify, in any degree, the opinion which we 
entertained from the first, that the course resolved upon was — putting 



564 INDUCTION OF PREMATURE LABOR. [CHAP. 

the child entirely out of consideration — that which gave the patient 
the benefit of the last ray of hope which remained for her. It is im- 
possible to detail all the conditions which may be supposed to justify 
a similar course, but we may mention dropsy of the amnion, fibrous or 
other tumors, albuminuria, convulsions, and mania, as among the cir- 
cumstances which have, in the experience of able practitioners, been 
found to call for the operation. 

Hie Operation. — As usually practiced, the induction of premature 
labor is a process in which operative aid plays an important, though a 
quite subordinate part. The accouchement forcee of the older French 
writers was a mode of procedure very different from this ; and, although 
the opponents of the English scheme did not scruple so to designate it 
in their bitter hostility, no analogy between the two can, in any sense, 
be admitted. A^arious as are the methods which have been practiced 
with a view to the expulsion of the foetus, these, with scarcely an ex- 
ception, consist, in so far as operative procedure is concerned, of expe- 
dients which are adopted with the view simply of inducing the uterus 
to expel its contents. These provocative measures are, as we shall see, 
very various ; but, so soon as uterine action has once been thoroughly 
excited, the further progress of the case is usually left to nature. The 
different modes of inducing uterine contraction, which are here referred 
to, were divided by Stoltz into two classes. The first of these embraces 
all methods which are supposed to act primarily upon the system, with 
the object of producing, secondarily, the effect which we desire ; the 
second comprehends all proceedings which may be adopted, with the 
view of operating directly upon the ovum or uterus, and thus stimu- 
lating, by reflex action, the latter to contract. 

The operation of such means as may be referred to the first class is 
too uncertain, and is, in fact, so little to be depended upon, that, in 
modern times, they have been entirely abandoned, especially in cases 
in which delay is to be avoided ; and there are, probably, no accouch- 
eurs of the present clay who would waste time in maintaining an ex- 
pectant attitude, in the hope that baths, bleeding, emetics, or even 
purgatives, might possibly produce what they desire. The only agent 
which, acting through the medium of the circulation, has still some 
supporters, is the ergot of rye. That this drug acts, in a large number 
of instances, upon the spinal cord, so as to influence the fibres of the 
uterus, is a fact which no one can gainsay ; but, in cases of abortion, 
and in all cases in which the uterus is in a state of quiescence, its action 
is more variable, and less to be depended upon, than when it is em- 
ployed during labor. While we reject it, therefore, as a provocative 
agent, there seems no good reason why we may not use it in many 
cases, — as we would in labor at the full time, — to expedite delivery, or 
to sustain flagging uterine effort. 

The other plan, — that of operating upon the ovum or uterus, so as 
directly to excite the contraction of the latter, has entirely superseded 
such of the more remote and indirect modes of procedure as have by 
some been practiced. We propose to direct attention here to the more 
important only of the numerous methods which have been devised 
directly to effect contraction. 



XXXIV.J THE OPERATION. 565 

1. The original mode of procedure, which received the support of 
the London Congress above alluded to, consists in the Rupture of the 
Membranes, by means of a quill sharpened at the point, or in any 
other way which may be considered more safe, in order to permit of 
the escape of the liquor amnii, and the partial collapse of the uterus. 
This is a very certain and effectual method of inducing premature 
labor, but it was soon found to be open to serious objections. In the 
first place, it compromises very decidedly the chances of the child, by 
allowing the uterine walls to come in contact with, and injuriously 
press upon it, in its imperfectly developed condition, from the beginning 
to the end of labor. And, secondly, it is far from being free from 
danger, especially in cases of abortion, when, owing to the imperfect 
dilatation of the cervix, the membranes are difficult to reach ; and many 
cases have occurred of serious and even fatal results, from injuries 
inflicted upon the cervical tissues in the course of those efforts, as has 
often been the case in recorded examples of criminal abortion. On 
these grounds, with the exception of certain cases of haemorrhage, in 
which, for special reasons, it is preferred to other methods, its use is to 
be condemned. 

2. Separation of the Membranes by means of the finger or sound 
introduced through the os uteri, was recommended and practiced by 
Professor Hamilton, of Edinburgh; but it may fairly be assumed that 
the result in such cases is due as much to the irritation and forcible 
dilatation of the os and cervix, as to the partial separation of the mem- 
branes, which is effected by sweeping the finger or sound round the 
uterus, so as to cause their detachment. Still, as the integrity of the 
membranes is in this way preserved, although, in many cases, it must 
necessarily be imperilled, this may be looked upon as an improvement 
upon the original process. 

3. The Dilatation of the Os by tents has also been practiced with 
considerable success, but in this case something more is attempted than 
a mere excitement to contraction, in the forcible dilatation of the parts, 
by which the natural process is in some degree aided. This latter in- 
dication is, however, more thoroughly carried out in the method which 
is now practiced by Dr. Barnes, as will afterwards be more particularly 
explained. 

4. The process which, in the opinion of most operators of the present 
day, is to be preferred, as combining, in the highest degree, the quali- 
ties of safety and efficiency, is the introduction within the uterus and 
outside of the membranes, of an Elastic Catheter, which is passed with- 
out a stylet for six or seven inches, and is allowed to remain in position. 
The presence of this is resented by the uterus, and, sooner or later, the 
organ is stimulated to contraction, as by any other foreign body. The 
risk of injuring or separating the placenta, which some have urged as 
an objection to this process, may practically be dismissed. With a 
stylet, that might possibly occur ; but, when the catheter is introduced 
properly, the resistance of the placental adhesion would, if encountered, 
be sufficient to turn aside the flexible stem. 

5. The introduction of Foreign Bodies into the Vagina has been 
trusted to by some as a means of inducing premature labor. It has 



566 INDUCTION OF PREMATURE LABOR. [CHAP. 

already been remarked, in discussing the treatment of the haemorrhage 
of abortion, that the great objection to the use of the plug was the 
danger, amounting almost to certainty, that the uterus would thereby 
be excited to expel its contents. As our object in the one case is to 
induce, what in the other we seek to avert, it may fairly be admitted 
that distension of the vagina, by Braun's Colpeurynter, Gariel's air 
pessary, or any other form of plug, is a safe method of provoking the 
uterus to contract, although tardy and uncertain in its action. 

6. The use of Vaginal or Uterine Injections was first suggested by 
Continental practitioners ; and, as both of these methods have received 
no inconsiderable amount of support in this country, it is proper that 
we should give to them some particular consideration. The method of 
Vaginal injection, which is known on the Continent as that of Kiwisch, 
has, in this country, received the support of Tyler Smith, Churchill, 
and other eminent accoucheurs. The process, as originally suggested, 
consists in directing a continuous stream of warm water upon the os 
uteri by means of a long tube, which is connected with a vessel placed 
several feet above the level of the patient. Some operators, trusting 
to the effect of the warmth of the injection, allow free egress of the 
fluid from the vagina, while others use measures to prevent its escape, 
with the view of effecting anatomical detachment of the membranes 
from the uterine wall ; and Tyler Smith expresses a preference for the 
alternate use of hot and cold water, as more certain to excite uterine 
action. The injection is to be repeated once or twice a day, for ten 
minutes or a quarter of an hour, when it seldom fails to bring on con- 
traction after eight or ten applications, and sometimes after two or 
three. Dr. Simpson substituted an ordinary Higginson's syringe, and 
various modifications of the original apparatus have, from time to time, 
been suggested. Simple and safe as this method may appear, later ex- 
perience has shown that it is by no means free from risk, and cases 
have been reported in which death had occurred ; so that, if it should 
be employed, caution must in every case be exercised ; and we appre- 
hend that it can only be adopted with perfect confidence, as regards the 
safety of the patient, when nothing is done to prevent the free escape 
of the fluid from the vagina. 

The intra-uterine douche, which is generally known as Cohen's 
method, was first recommended by Schweighauser in 1825. It was 
originally introduced as an improvement upon Hamilton's process, as, 
in its operation, it more thoroughly and effectually separates the mem- 
branes from their uterine attachments. Abundant proof has been 
afforded that this is an effective plan, but it remains for our considera- 
tion whether or not it is to be admitted as a safe one. Dr. Barnes has 
collected no less than ten cases in which a fatal result ensued from the 
employment of the uterine douche, in some from shock, in others, as 
has been assumed, from the passage of the injected fluid through the 
Fallopian tubes into the abdominal cavity, and in others, as in a case 
which he quotes from Ulrich, by the entrance of air into the circulation 
through the uterine sinuses. In two cases mentioned by Simpson, the 
cause of death was rupture of the uterus. " The occurrence/' he says, 
" of the rupture was to be explained by the fact, that the uterus, being 



xxxiv.] barnes's method. 567 

already fully distended, could not admit the few ounces of fluid with- 
out being stretched and fissured to some extent ; and during labor 
these slight fissures might easily be converted into fatal ruptures. In 
one case, the patient died before labor was completed ; in the other, 
in twelve hours after its termination." It has also been urged by the 
same authority, that the placenta may be detached by injection ; and 
that the position may possibly be altered, so as to change a cranial into 
a transverse presentation. 

While we cannot wonder that the methods above described have 
received much support from influential quarters, we fear that such 
results as have been reported must be taken as a sufficient warrant for 
the absolute condemnation of the syringe as a means of inducing labor. 
Some doubt may be admitted as to the original plan of Kiwisch ; but, 
when this is combined with forcible distension of the vagina, by pre- 
venting the escape of the injected fluid, which is tantamount to Cohen's 
method, we feel that no evidence of mere efficiency, nor accumulation 
of successful results, will warrant us in exposing a patient to such 
danger, while, undoubtedly, safer means are at our command. Injec- 
tions of carbonic acid gas, and of common air, within the cavity of the 
uterus have also been practiced, but with such results as to deter any 
one from such expedients in all time coming. 

7. The most recent method of inducing premature labor, is that 
which was suggested about ten years ago by Dr. Barnes, of dilatation 
of the os and cervix by means of graduated fluid pressure. A similar 
mode of procedure had previously been attempted by Dr. Keiller and 
Mr. Jardine Murray ; but it is to Dr. Barnes that we certainly owe the 
complete scheme of cervical dilatation, which is in the present day 
gradually making its way into practice. The plan originally pro- 
pounded by Dr. Barnes commenced by forcible dilatation of the os 
uteri, and was one, therefore, to which the French opponents of the 
general scheme would have applied their favorite term accouchement 
forcee, with the full weight of the contemptuous epithet ; and to the 
modified procedure which he now advocates the same term might still, 
in a qualified sense, be applied. 

His process now consists of two stages — provocative and accelerative. 
For the first of these, and for reasons similar to those which have been 
advanced in the preceding pages, he prefers the fourth of the methods 
which we have described. Overnight he passes an elastic bougie six 
or seven inches into the uterus, and coils up the remainder of the in- 
strument in the vagina. Under favorable circumstances, some uterine 
action will have been set up by the following morning ; and, if not, it 
must still be left in situ for a time, until it is evident that the provoca- 
tive action has been established. " Before rupturing the membranes," 
he says, "adapt a binder to the abdomen, and let this be tightened, so 
as to keep the head in close apposition to the cervix. This will often 
prevent the cord from being washed down by the rush of liquor amnii. 
Dilate the cervix by the medium or large bag, until it will admit three 
or four fingers. Then rupture the membranes, and, before all the 
liquor amnii has escaped, introduce the dilator again, and expand until 
the uterus is open for the passage of the child. If the presentation is 



568 



INDUCTION OF PREMATURE LABOR. 



[chap. 



Fig. 192. 



natural, if there is room, and if there are pains, leave the rest to nature, 
watching the progress of the labor. If these conditions are not present, 
and one or other is very likely to be wanting — proceed with accelera- 
tive methods — that is, to the forceps or turning ; or, in cases where the 
passage of a live child is hopeless, to craniotomy. By pursuing this 
method, we may predicate, with great accuracy, the term of the labor. 
Twenty-four hours in all — counting from the insertion of the bougie — 
should see the completion of the labor. The personal attendance of 
the physician during two hours is generally enough. The mode of 
proceeding must vary according to the conditions of the case." Writing 
in 1862, he says, " It is just as feasible to make an appointment at any 
distance from home to carry out at one sitting the induction of labor, 
as it is to cut for the stone." 

The fiddle-shaped bags referred to in the above extract are of the 
form shown in the accompanying illustration. They are so constructed 
as to be grasped in the middle or constricted part by the os and cervix, 
which prevents them from slipping upw T ards 
into the uterus, or downwards into the vagina. 
Their introduction is effected by means of the 
little cup-shaped pouch which is attached exter- 
nally, into which the point of the uterine sound 
may be adapted, and from which it may subse- 
quently be withdrawn. Being first emptied of 
air, and folded upon itself, the stop-cock at the 
end of the tube being closed, it is passed in this 
shape through the cervix. The nozzle of a 
syringe, which has previously been filled with 
water, is now adapted to the tube, through which 
the fluid is cautiously injected. After moderate 
dilatation of the bag, the stop-cock is again 
closed, and the syringe removed, when the bag 
will be found to be firmly fixed in its place. A 
little practice, as w 7 e have learned by experience, 
is necessary in the management of this instru- 
ment, and especially of the stop-cock ; but a 
close observation of the apparatus, and a few 
test-experiments before its introduction, will ob- 
viate any difficulty, and will at the same time serve to insure the effi- 
ciency of the bag. The process of subsequent dilatation should be 
gradual, and is effected by repeated injections, which, while increasing 
the size of the bag, exercises a pressure or dilating force upon the cervix, 
which is perfectly equable, and which is a pretty close imitation of the 
manner in which nature effects dilatation by means of the sac of the 
liquor amnii. It may be necessary to use successive bags, which pro- 
gressively increase in size ; or, in the absence of a sufficient assortment, 
two bags may be simultaneously introduced, and successively dilated, 
until the requisite amount of distension is attained. The only objection 
which occurs to us, as one which may possibly be urged against the use 
of this contrivance, is the chance of the displacement of the presenting 
part, by the expansion within the uterus of the fundus of the bag; but 




Barnes's uterine dilators. 



XXXIV.] CONSTITUTIONAL INFLUENCES. 569 

in so far as experience has gone, in the hands of the inventor, or of 
those who have adopted his process, it does not appear that this objec- 
tion has been experienced in actual practice. For our part, we have 
repeatedly had occasion to use the apparatus, and, so far as a limited 
experience may entitle us to form an opinion, we can, in every respect, 
corroborate the assertions which have been made in its favor. 

The methods of inducing premature labor which have been above 
detailed do not, it need scarcely be said, embrace all that have been sug- 
gested and practiced. At a very early period of the controversy, Gal- 
vanism was looked upon by some as an agent from which important 
results might be expected ; but, although this is a powerful and un- 
doubted provocative to the uterine contraction in some cases, it is so 
uncertain, that its use has now been abandoned — as has also been the 
case with regard to many other expedients, from which at one time 
brilliant results were looked for. Scanzoni has suggested an ingenious, 
but rather fanciful method, depending upon the well-known sympathy 
which exists between the mammae and the uterus. He has applied — 
and in two cases, at least, with success — an apparatus of the nature of 
an exhausting syringe, or sucking-pump, over the nipple for about two 
hours, the irritation thus produced being propagated by sympathy to 
the uterus. Most of the other methods suggested are either modifica- 
tions of processes already described, or are not of sufficient importance 
to require special consideration. 

The condition of the ovum, the uterus, and the system generally, in 
reference to this operation, are obviously points of no little importance. 
The question of viability or non-viability of the foetus having been de- 
termined by the period of pregnancy, the fitness, anatomically and 
physiologically, of the maternal parts, and indirectly, that of the general 
system of the mother, naturally attract attention. In deciding upon 
the operation, we necessarily resolve upon a proceeding which, in a 
manner, takes nature unawares. The condition of the cervix at various 
periods of pregnancy, has been fully referred to in a previous chapter. 
It is but natural, therefore, that we should anticipate difficulties, in 
proportion to the extent to which the case is removed from the full 
term of gestation. But, in practice, it is truly wonderful how nature 
seems to adapt herself to the exigencies of the case ; for, not only do 
the parts yield, to an extent upon which mere speculation would not 
entitle us to rely, but the whole system seems to lend itself to our pur- 
pose. The breasts enlarge and milk is secreted, after the seventh month 
at least, and often earlier, for the sustenance of the infant, just as if 
pregnancy had run an uninterrupted course. The dangers of parturi- 
tion may be to some extent, but, in truth, are scarcely sensibly aug- 
mented ; nor are certain after-effects of mature parturition — which have 
yet to be detailed — much, if at all, more likely to accrue. 

This brings to a conclusion what is generally termed Operative Mid- 
wifery. The various modes of procedure which in this and previous 
chapters have been described, do not, of course, include every skilful 
tour de main which the experienced or ingenious practitioner will, under 
special or peculiar circumstances, adopt. The object of the author has 



570 OBSTRUCTIONS TO LABOR. [CHAP. 

been rather to point to general principles, than to elaborate details 
to which the increasing scientific accuracy of the art is daily giving 
precision. 



CHAPTER XXXV. 

LABOR OBSTRUCTED BY MATERNAL SOFT PARTS. 

RIGIDITY OF THE OS: USE OF ANAESTHETICS AND OF BELLADONNA: FORCIBLE 
DISTENSION: INCISION IF OS OCCLUDED — EFFECTS OF UTERINE DISPLACEMENT 
— ABNORMAL CONDITIONS OF THE VULVA AND OF THE VAGINA : RIGIDITY : 
PERSISTENT HYMEN : CICATRICES FROM SLOUGHING : TREATMENT OF THESE 
CONDITIONS — VAGINAL THROMBUS — UTERINE POLYPUS; MANAGEMENT OF, 
WHERE IT OBSTRUCTS LABOR — OVARIAN TUMORS — FECAL ACCUMULATION IN 
THE RECTUM .* RECTOCELE — DISTENSION OF THE BLADDER: CYSTOCELE — STONE 
IN THE BLADDER AN OCCASIONAL IMPEDIMENT — HERNLI — OTHER TUMORS 
WHICH MAY IMPEDE LABOR — MALIGNANT DISEASE OF THE CANAL. 

In treating of the management of natural labor, various obstructions, 
arising from the condition of the soft parts, were necessarily alluded to. 
The form under which obstruction of this kind most frequently presents- 
itself is that of Rigidity, either of the os uteri or of the perineal struc- 
tures. Generally speaking, this is an occurrence which exists quite 
independently of any diseased condition of the parts, and is, in fact, a 
purely functional lesion, yielding, as all experience has shown, to time ; 
or to bloodletting, tartar emetic, chloroform, and the warm bath. 
Such obstructions as this may exist in every conceivable degree, from 
that which causes but a trifling delay, to the more obstinate forms 
which only yield after long-continued, and possibly exhausting labor. 
But, in addition to these, there are yet other cases in which the ob- 
struction of the os is of a more serious nature, depending either upon 
peculiarity of structure or actual disease ; and it is in cases such as 
these, as was before mentioned, that the force of the uterine contraction 
has been so great as, in some rare instances, to separate the os and 
cervix, in the form of a ring, from the rest of the uterus ; or, in some 
more common way, to produce rupture of the organ. 

There are some cases in which there seems to be actual occlusion of 
the os, such as is sometimes observed in the unimpregnated uterus. 
Impregnation in the case of an absolutely occluded os is as impossible 
as that the normal function of menstruation should be carried on ; and 
therefore, we assume, in such cases, that the closure must have taken 
place subsequently to the entrance of the seminal fluid. It is, of course, 
possible, that the os may remain open to a very limited extent, and yet 
the state of the tissues render distension impossible, so as practically to 
constitute an impediment as insurmountable as actual occlusion would 
be. In cases of anteversion of the gravid uterus, which is associated 



XXXV.] OCCLUSION OF THE OS. 571 

with pendulous abdomen, one result of the displacement is that the os 
uteri is tilted upwards and backwards beyond the reach of the finger, a 
condition which might readily enough be mistaken for occlusion, unless 
the observer should take the precaution to introduce the hand within 
the vagina, so as to explore thoroughly that part of it which is towards 
the hollow of the sacrum. Injuries, the result of former labors, the 
indiscriminate use of cauterants, and some other similar causes, may 
give rise to a species of callous rigidity, which is scarcely to be over- 
come by any means short of actual incision ; and in the worst cases of 
all, in which the tissues are the seat of induration from cancerous 
disease, the barrier may be so impassable as to render necessary the 
desperate expedient of the Caesarian Section. 

In bygone times, the treatment of rigid os consisted in the free use 
of the lancet, the administration of tartar emetic, and the employment 
of the warm bath. That these agents have the effect, in most cases, of 
overcoming simple rigidity is certain ; but, in the present day, anaes- 
thetics are always preferred as being safer, simpler, and equally reliable. 
Chloroform is usually preferred ; but recent observations would seem 
to indicate that the effect produced by chloral hydrate is even more 
marked. [Under certain circumstances the preparations of opium are 
among the most useful remedies that can be administered for the relief 
of rigidity of the os. This remedy is particularly useful in weak 
women with irritability of the nervous system and deficient muscular 
force. Such persons often have ineffective pains for a long time, the os 
uteri being scarcely affected by them. A dose of morphia, or any other 
preparation of opium, large enough to secure two or three hours' sleep, 
will often be followed by rapid relaxation of the os. Indeed, w r e have 
seen a rigid os, which had remained unchanged for hours, become relaxed 
and undergo complete dilatation during a couple of hours' sleep induced 
by a large dose of morphia. — P.] Belladonna, in the form of injection, 
is much extolled by the French accoucheurs ; but this is an expedient 
which is to be resorted to with caution, as faintness, headache, vertigo, 
and the other constitutional effects of the drug, are apt unexpectedly to 
be induced. The cases, according to Cazeaux, in which belladonna is 
most likely to do good, are those in which there is not rigidity, but 
spasmodic contraction of the fibres of the neck, an active and not a 
passive force. Although the os may, in ordinary cases, with scarcely 
an exception, be readily detected by the finger, it would appear that 
there are instances in which, although it has been impossible to feel it, 
its presence has been revealed to the eye by the speculum. This at 
least is an assertion which has been made by some whose opinions must 
always command respect; but it appears to us that the difficulty of 
using the speculum in labor, and the impossibility of recognizing the 
os when it is high in the hollow of the sacrum, must render this mode 
of investigation a very unsatisfactory one. The treatment of labor 
obstructed in this way may come to be a matter involving considerable 
perplexity. If the os, or the situation where surrounding induration 
marks the point at which it has become occluded, can be discovered, 
mechanical means, such as sponge-tents, and the like, must be used for 
its dilatation ; but when no aperture whatever can be distinguished, 



572 OBSTRUCTIONS TO LABOR. [CHAP. 

even when uterine action has been in operation for some time so as to 
bear upon the inferior segment of the uterus, no course remains for us 
but to incise the organ at its most dependent part, and thus avoid the 
danger with which the woman is threatened. 

The necessity for such an operation being once recognized, no advan- 
tage, but the contrary, will ensue from delay. Beyond a certain degree 
of uterine effort, all that is essential is the presence of such pains as 
may secure the passage of the head so soon as a channel is opened up 
for it. The effect of delay, indeed, in such a case, would be to incur 
the danger of rupture of the uterus, and to allow the period to pass at 
which the patient is best able to bear the continued strain entailed by 
the ordinary phenomena of propulsive labor. In so far as the opera- 
tion is concerned, the incision should be made from before backwards, 
by a blunt-pointed bistoury, or by a series of incisions radiating from 
the real or imagined site of the occluded os. Great care should, of 
course, be taken not to wound the rectum or bladder ; and the reason 
why the antero-posterior direction is preferred is, that the uterine 
arteries may with certainty be avoided. The incision should be made 
to a limited extent only, for, the breach being once effected, and uterine 
effort being present, the head will, partly by stretching and partly by 
tearing, open a passage for itself as it is forced onwards. A number 
of morbid conditions of the os and cervix have occasionally been ob- 
served to cause serious obstruction to labor. Of these the most impor- 
tant is, of course, cancer; but there are oases in which induration and 
hypertrophy of the whole cervix, or it may be of the anterior lip only, 
has constituted an impediment scarcely less formidable. In some 
instances, it would appear that the cause of obstruction may be an 
hypertrophied and elongated condition of the cervix, as in a case 
reported by Mr. Roper, in the Obstetrical Observations for 1866. The 
treatment proper to such a condition would be dilatation by means of 
sponge-tents, or by air or water bags. Abscess and thrombus of the 
lips of the os have also been encountered as rare impediments to the 
passage of the child. 

The more important displacements of the gravid uterus have already 
been spoken of; and, from the observations then made, the influence 
which such malpositions may exercise upon the course of pregnancy 
may be in a great measure inferred. The effect of displacement for- 
wards — anteversion or anterior obliquity — of the uterus must necessa- 
rily be to throw the os backwards; and, at the same time, the axis of 
propulsive action deviates from that which is normal in proportion to 
the extent of the displacement. If, along with this, there is any con- 
traction of the pelvic brim, the result of the misdirected force may be 
that the head does not become engaged in the cavity, and that the 
anterior and inferior part of the uterus is exposed to injurious pressure. 
This condition of matters — which is recognized by a combined abdomi- 
nal and vaginal exploration — may best be remedied by raising the 
depressed fundus, and maintaining it in that position by a bandage. 
In this way, the axis of the uterus is brought more into coincidence 
with that of the brim, a result which may be still further insured by a 
supine position. 



XXXV.] EFFECTS OF UTERINE DISPLACEMENTS. 573 

Posterior and lateral obliquities have also been noted as impediments 
to delivery, but to these unnecessary prominence is given by most Con- 
tinental authorities. In the former case, the os will probably be dis- 
cerned in front, behind the symphysis; and, in lateral obliquities, the 
os will be directed to the side opposite to that to which the fundus 
is inclined. Although practical difficulty from these obliquities is rare, 
it may happen that the head remains above the brim, while the shoul- 
der which is lowest in the uterus, slipping down, becomes the present- 
ing part. 

An abnormal condition of the vulva and vagina, congenital or other- 
wise, may sometimes cause serious obstruction to the course of labor. 
Union of the labia and nymphge may exist to a greater or less extent ; 
and, as the smallest possible vaginal orifice is all that is essential to 
impregnation, an obstacle of this kind, whether congenital or the result 
of cicatricial union and contraction, may require the aid of art. The 
persistence of the hymen is another condition of a similar kind, which 
has sometimes been observed to such an extent as to constitute an im- 
passable barrier. An extreme rigidity of the external parts has been 
noticed, chiefly in the case of women who become pregnant for the first 
time, either at an advanced age or very young. This rigidity of the 
perineum will generally yield to the vigorous pressure of efficient labor 
pains ; but it sometimes happens that the resistance is obstinate, and 
requires assistance. In' all these cases, incision should not be practiced 
until the head has descended to the perineum, and then only to such 
an extent as may be absolutely necessary, remembering always that a 
trifling incision thus made will be extended as the head advances. 

Our anxiety, in such circumstances, would be chiefly directed to the 
perineum, a laceration in which may, as we have seen, prove a very 
serious matter, by running back into the rectum. In order to avert 
such a catastrophe, therefore, we should make the incision, not in the 
middle line, but on either side, so as to direct the tear laterally and 
not posteriorly ; and, even when such lacerations may have a formida- 
ble appearance at the moment of birth, they will rapidly contract, and 
a few days afterwards will be no longer visible. If the obstacle depends 
— whether in the vagina or at the orifice — upon contraction which is 
the result of disease or previous laceration, the difficulties of the case 
may be very great. Not unfrequently the cicatrices are formed of 
strong ligamentous bands, which prevent the distension of the vagina, 
and may even pass across from one side of the canal to the other as 
imperfect septa. It has been recommended, when this is recognized 
early, that gradual dilatation should be attempted by means of tents or 
bougies. In the minor cases, the stricture will ultimately yield before 
the pressure which, during labor, is brought to bear upon it from 
within ; but, in the worst cases, operative interference will be required. 
It has been found that free incision of such vaginal cicatrices is apt to 
be followed by serious haemorrhage. What, therefore, is a much safer 
plan is to act in the same manner as we have recommended in incisions 
practiced at other portions of the parturient canal. A number of su- 
perficial incisions, or scarifications, parallel to the axis of the vagina, 
will, when the head descends, yield, and admit of tearing, which should 



574 OBSTRUCTIONS TO LABOR. [CHAP. 

be effected to such an extent only as may be necessary for its passage. 
Such tearing is, of course, free from the ordinary risks of haemorrhage ; 
but a moderate amount of bleeding is, perhaps, rather to be desiderated 
than otherwise, as it will tend to promote relaxation of the parts. The 
division of bands or septa may be conducted upon the same principle; 
and it has been recommended that we should partially divide them 
cautiously during the pain, even allowing the knife to be forced by the 
pain against the obstruction. If it does not speedily yield, the finger 
may be used freely to encourage the tearing asunder of these structures, 
using the knife as little as may be practicable. In this way the diffi- 
culty will gradually be overcome, and the descending head will make 
its way, or may even be assisted by the forceps. 

The vagina may be very small, or contracted congenitally at some 
part of its length, or in its whole extent, — the canal, although sufficient 
for the purposes of impregnation or menstruation, being utterly inade- 
quate for the function of parturition. Should such a condition as this 
call for operative procedure, it will be necessary to give relief to the 
constriction by cautiously combining tearing with incision, as in the cases 
of contraction from adhesion, adopting such means as may be best 
suited to protect the adjoining hollow viscera from injury. 

Again, the soft parts may be the seat of diseased conditions, giving 
rise to Tumors of any portion of the canal, which may prove mechanical 
impediments to labor. GEdema of the vulva has already been men- 
tioned as an occasional result of pregnancy, and it would appear that 
sometimes this exists to such a degree as to constitute a mechanical 
obstruction. Thrombus of the vagina — which is observed both during 
gestation and after delivery — occasionally, by its unusual development, 
bars the passage of the head, and at the same time presses injuriously 
upon the bladder and the rectum. These tumors, depending as they 
do upon the rupture of bloodvessels, usually make their appearance 
suddenly — a diagnostic feature which is of considerable importance. 
Sometimes the blood infiltrates the cellular tissue, and at other times it 
is accumulated within cavities which it forms for itself; and, in the 
latter case, a certain degree of modified fluctuation will probably be 
observed, while the pain by which the original tumefaction has been 
accompanied, and the bluish color which the tumor exhibits externally, 
will generally suffice to indicate, with precision, the nature of the case. 

The prognosis of vaginal thrombus, whether occurring during preg- 
nancy, labor, or at a more advanced period, is very serious. " Of 
sixty-two cases," says M. Deneux, " which have come to my knowl- 
edge, the mother has succumbed in twenty-two ; and, with the excep- 
tion of a single case, the children in those twenty-two cases were lost." 
In cases which prove fatal, the loss of blood seems to be the immediate 
cause of death; but in those instances in which the primary risk is 
avoided, gangrene or suppuration may ultimately be the cause which 
leads to the fatal result. We have at present nothing to do with the 
treatment of thrombus occurring during pregnancy or after labor ; but 
in those cases in which it constitutes an actual obstacle to delivery, 
nothing is open to us beyond free incision, which may be made in the 
most dependent portion of the tumor, and of such size as its dimen- 



XXXV.] 



UTERINE POLYPUS. 



575 



sions may seem to render necessary. The immediate effects of gan- 
grene and suppuration, and their probable results, will, of course, in 
such a case excite, and with good cause, the serious apprehension of the 
accoucheur. Among the other tumors which may be encountered 
during labor, we may mention, in addition to those which have already 
been detailed, phlegmonous enlargements, cysts, syphilitic vegetations, 
and such tumors as have been figured by Martin in his Atlas, as due 
to hypertrophy or degeneration of the nymphae and preputium clitori- 
dis, — all of which must be managed on ordinary surgical principles. 

Polypoid tumors, springing from the uterus, may sometimes con- 
stitute very serious obstacles to delivery, as is here shown. The mere 
existence of a tumor of this character is not, however, to be accepted 



Fig. 193. 




Uterine polypus as an obstacle to delivery. 



as evidence of a condition which absolutely prohibits the passage of 
the child, as much will depend upon the mobility as well as the com- 
pressibility of the tumor. In a case published by Dr. Beatty, to 
which Dr. Churchill refers, " the tumor was so large and apparently 
so fixed, that Caesarian Section was anticipated ; nevertheless, at the 
time of labor, it was elevated sufficiently to allow of the birth of the 
child without any assistance." In some cases of polypi with a narrow 
pedicle, the effect of continued pressure and extensive effort has been 
to detach the growth, and expel it in advance of the child. The man- 
agement of such cases will depend, in a great measure, upon the con- 
ditions already mentioned. If, for example, it is movable, and the 
head has not yet descended into the pelvis, so as to render such a result 
impossible of attainment, we should try, as has in some instances been 



576 



OBSTRUCTIONS TO LABOR. 



[CHAP. 



done with success, to push the tumor upwards during the interval 
between the pains, and retain it in its elevated position until the head 
takes precedence of it in its descent. Should this, however, fail, the 
nature of the tumor being undoubted, the proper treatment will be to 
remove it, which may be effected with the least possible risk by means 
of the wire ecraseur. 

In some cases of ovarian disease, the tumor, instead of developing 
upwards, as is usual, in the direction of the abdominal cavity, falls 
downwards into the pouch of Douglas, between the rectum on the one 
hand, and the uterus and vagina on the other. Such a condition will, 
no doubt, as a rule, give rise to abortion or premature labor ; but, as 
the system is often slow to respond to such influences, it may happen 
that pregnancy, under these circumstances, goes on to the full term. 
In such a case as this, the obstacle, mechanically speaking, is much the 



Fig. 194. 




Ovarian tumor obstructing deliver) 



same in the case of the uterine polypus just alluded to, as is shown in 
the accompanying figure. The anatomical relations of a tumor such as 
this are widely different from the other case, as it is to be reached, not 
within the vulvo-uterine canal, but by perforation of the peritoneum 
either from that side or from the rectum. Such tumors vary considera- 
bly both in size and form, and the first point, therefore, upon which it 
is necessary to decide is, whether or not it is of such a nature as to con- 
stitute an impossibility, or merely a difficulty, in the passage of the 
foetus. This will depend in a great measure upon the structure of the 
tumor. Such growths are, as is well known, most frequently cystic in 
their nature, and, consequently, admit of a considerable amount of flat- 
tening, which would also be encouraged by the elasticity of their walls. 
The benefit of this mechanical advantage may, however, be lost by the 



XXXV.] OVARIAN TUMORS. 577 

nature of the pressure which is exercised by the advancing head ; for, 
if the higher part be firmly pressed, as is quite possible, between the 
head or other presenting part and the pelvic brim, so as to bring the 
walls of the cyst into complete apposition, the lower portion may bulk 
still more prominently during a pain, and be rendered at that moment 
harder and more resistant. We should not, in such a case, confine our- 
selves to vaginal exploration, but endeavor, by the introduction of one 
or more fingers into the rectum, to ascertain the nature of the case, 
with such precision as may be possible under the circumstances. 

The treatment applicable to these cases must obviously depend upon 
the information to be derived from such examination as may be practi- 
cable. If the volume, seat, and nature of the tumor seem to encourage 
the belief that the forces of nature may prevail, we should do nothing 
further than to make sure, by securing an empty condition of the blad- 
der and rectum, that no extraneous influence exists, which may further 
complicate the acknowledged difficulties of the case. If, however, a 
purely expectant treatment should not result in the progress which we 
desire, it will be proper to attempt to push the tumor beyond the upper 
boundary of the pelvis; but, if it should show a tendency to fall back, 
which will generally happen during the interval between the pains, we 
must attempt to retain it in such a position as may enable us to apply 
the forceps or to introduce the hand for the purpose of version, in which 
latter case the arm of the operator in the vagina will prevent the tumor 
from again descending towards the floor of the pelvis. 

In cases in which the descent of the head, or the existence of adhe- 
sions, renders any displacement of the tumor impossible, it is even of 
greater importance that we should recognize, what is not always an 
easy matter, whether or not it is cystic. If so, and we leave it to na- 
ture, the result will probably be either rupture and escape of its con- 
tents into the cavity of the peritoneum, or a violent inflammatory action, 
the result of pressure. The puncture of such cysts from the vagina, as 
advised by Merriman, has been practiced with perfect success, and is 
obviously the only method of treatment which is open to us. To ob- 
viate the possibility of an error in diagnosis, an exploratory trocar 
should, in the first instance, be passed into the tumor, and when its na- 
ture is thus conclusively demonstrated, a larger trocar and canula may 
be employed, and the contents as thoroughly as possible evacuated. 
Complete success can, under such circumstances, only be counted upon 
when the cyst is unilocular ; but when it is a multilocular cyst, or the 
contents are unusually thick, it has been found necessary, in order to 
lessen the tumor, to incise from the vagina, a mode of procedure which, 
although dangerous, is probably less so than the doubtful results of the 
accidents which we have indicated as likely to supervene. Some have 
proposed puncture by the rectum ; but, as the dangers of this operation 
are greater than the other, it ought to be rejected, unless, perhaps, 
under very peculiar circumstances. 

When the tumor is solid, the difficulties of the case are greatly in- 
creased. In such a case, it being impossible to push it back, we have 
to balance the chances of embryotomy or the Caesarian Section against 
an operation which has for its object the separation and removal of the 

37 



L 



578 OBSTRUCTIONS TO LABOR. [CHAP. 

growth. Merriman recommends that, if we can convince ourselves of 
the absence of serious adhesions, we should proceed by the method of 
extirpation ; but, putting aside the difficulty of determining this point 
before the operation has actually been commenced, we fear that this 
procedure can seldom be justifiable. If the tumor be of such a size as 
to leave an available gap of an inch and a half or two inches in the 
pelvis, the operation of craniotomy would, we think, with the im- 
proved appliances now at our command, afford a much better prospect 
of success ; and, even when this hope is denied us, the Caesarian opera- 
tion, if performed early, would give the patient a better chance than 
removal of the tumor, and might at least have the effect of saving the 
child. The result of all these operations has, however, been extremely 
unfavorable. 

An accumulation of hardened faeces in the rectum has occasionally 
proved a very serious obstacle to labor. Such a condition can, of 
course, only happen where there has been great carelessness, and ne- 
glect of the function, so as to permit the lodgment of such a mass 
within the rectum as may actually bar the advance of the head. The 
treatment obviously indicated in such a case, is the relief of the bowels 
by means of emollient enemata ; but, should these fail, owing to the 
size or extreme induration of the mass, it may be necessary to scoop out, 
or otherwise remove the contents of the rectum, and in one way or 
other the tumor will usually be dissipated without difficulty. The only 
other affections of the rectum which may be supposed to impede de- 
livery are scirrhus, which has seldom been observed of such a size as 
to form a serious obstacle, and rectocele, in which the lower part of the 
gut protrudes into the vagina. 

On the opposite side of the vaginal canal, the condition of the blad- 
der may exercise an obvious influence on the progress of the case. The 
importance, not only in obstetrical operations, but in ordinary practice, 
of attending to that viscus, so as to protect it from the effects of dis- 
tension, is a point, as has already been repeatedly mentioned, of the 
highest importance, *as neglect of this not only endangers the bladder 
itself, but also may form an obstruction to labor. Cystocele, as an im- 
pediment, consists in the protrusion of the neck and lower part of the 
bladder in the direction of the vagina, forming a tumor of such size as 
to prevent the passage of the head. The idea usually entertained of 
this seems to have been that it is due, in a great measure, if not en- 
tirely, to neglect of the usual precautions for insuring the evacuation 
of the bladder; but we are at one with Dr. Tyler Smith in supposing 
that this, although a possible cause, is certainly not the usual one. 
Prolapse of the bladder is by no means an uncommon, and is some- 
times a very troublesome affection, in women who have borne large 
families; and, when a woman in whom this occurs becomes pregnant, 
we may be pretty sure that unless special care be taken at the time of 
delivery, difficulties are extremely likely to arise. The impediment 
will best be obviated by the opportune use of the catheter; and if the 
cystocele already exists as an obstruction, care must be taken to pass 
the catheter backwards into the tumor, or to raise and press upon the 
latter so as to insure its evacuation. Caution must be exercised in the 



XXXV.] STONE TN THE BLADDER. 579 

diagnosis of this affection, for it has happened that the fluctuating sac 
has been mistaken for the membranes, and perforated with the view of 
giving exit to the liquor amnii, the assumed cause of the obstruction. 
It has also been mistaken and punctured, in a case reported by Merri- 
man, for a hydrocephalic presentation. 

An interesting illustrative case, in which the tumor was of consider- 
able size, is narrated by Madame Lachapelle. " The first thing," she 
writes, " that attracted attention was a pediculated tumor, about the 
size of an egg, which, projecting a little from the vulva, seemed to be 
attached to the anterior and right wall of the vagina, about its middle 
part. The pedicle was about an inch and a half in thickness, and the 
tumor contained a fluid which could be completely pressed out of it 
through the pedicle, when we were able to feel an aperture with thick- 
ened borders, which appeared to me to communicate with the bladder. 
In reference to the position of the woman, it was found that the tumor 
increased in size in the erect posture; it often disappeared after mic- 
turition, and was always retracted under the influence of a cold bath. 
The uterine contraction increased the volume of this hernia, and the 
head, in its descent, pushed it in advance, and stretched it strongly. I 
reduced it after having emptied the bladder, and I recommended the 
pupils to support it with two fingers during each uterine contraction. 
The head soon cleared the passage, and itself retained the hernia, and 
the labor terminated happily." 

A urinary calculus may, of course, coexist with the pregnant state, 
but will usually produce no effect, mechanical or otherwise, upon the 
progress of gestation. In rare instances, however, it has been found 
that the stone has been so placed as to be imprisoned in the lower 
segment of the bladder by the pressure of the head of the child against 
the pubis. The advance of the head still further tends to confirm this 
position, and, ultimately, the stone, encroaching, as it does, upon the 
calibre of the pelvic canal, constitutes a serious impediment to delivery. 
The diagnosis is not always easy, but if the tumor behind the pubis is 
hard, circumscribed, and evidently situated beyond the pelvis; if it is 
fixed during contraction, and movable during the relaxation of the 
uterus, the symptoms are sufficiently significant to indicate the use of 
a sound, which will at once disclose the nature of the case. The cir- 
cumstance in which a calculus is most likely to be an obstacle to labor, 
is when it is complicated with vaginal cystocele — an anatomical con- 
dition of the parts obviously favoring the descent of the stone by gravity. 
Smellie gives among his cases that of the wife of a coal porter, who, 
having long suffered from the symptoms of stone, became pregnant. 
She was attended during labor by a midwife, who recognized the pres- 
ence of a hard body in advance of the head, but, her resources being 
limited, she was content to wait and watch the progress of events. 
Ultimately, a hard and rounded substance of considerable size was 
extracted from the vagina, which, on examination, was found to be a 
calculus of large size. The removal of the obstacle admitted of the 
immediate passage of the child; but the incontinence of urine, which 
remained, was, undoubtedly, due to vesico-vaginal fistula — an accident 
then considered irremediable. 



580 OBSTRUCTIONS TO LABOR. [CHAP. 

The treatment of all such cases will consist — if the period has not 
already passed when this may be effected — in attempting to push the 
stone upwards into that part of the bladder which is above the brim, 
and, if necessary, retaining it there during the intervals between the 
pains, until the head shall descend, so as to prevent its slipping down 
again. If the head has already made some advance in its passage 
through the pelvis, it may still be possible to push up the stone by 
operating during the interval between the pains, if only we can displace 
the head a little so as to admit of its passage upwards. But, if the 
calculus is so placed that it is impossible to dislodge it from its position, 
the case may become a very serious one, as the only remaining resource 
will then be the removal of the body which prevents the accomplish- 
ment of the function of parturition. The safest mode of procedure, as 
to its immediate results, would, under such circumstances, probably be 
the dilatation of the urethra and the extraction of the stone. Such an 
operation is, however, open to two objections. In the first place, it 
can only be safely performed slowly, a condition which obviously does 
not suit the exigencies of the case; and, again, it leaves most unsatis- 
factory results in a long continuance of incontinence of urine. It is 
probable, therefore, that the most judicious course would be, when the 
obstacle seems such as to preclude the possibility of safe delivery by 
the forceps or turning, to perform the operation of vaginal lithotomy, 
cutting down upon the stone through the neck of the bladder, and 
removing it in the usual way. The operation of lithotrity has also 
been suggested ; but, in so far as we arc aware, it has never been 
practiced. 

Certain rare forms of hernia may coexist with pregnancy, and may 
even form impediments to the termination of labor. It is, it must be 
confessed, very unlikely that such tumors should, in any considerable 
degree, oppose the passage of the child ; but there undoubtedly exists 
the more indirect, but not less serious danger, which arises from com- 
pression or strangulation of a hernial tumor, wherever situate. Such 
hernise have been observed in the posterior part of the pelvis, the 
bowel, or omentum, or both, having descended, in the first instance, 
into the cul-de-sac of the peritoneum which lies between the vagina 
and the rectum, making its way downwards in the same direction, until 
it may ultimately protrude at the perineum, and form a perineal hernia ; 
while, if it bulges into the vagina, it is a vaginal hernia. The protru- 
sion may also take place from a different quarter, the bowel passing 
along the canal of Nuck, and ultimately forming a tumor in the labium 
of either side, which is anatomically analogous to scrotal hernia in the 
male. The diagnosis of these tumors will seldom cause much per- 
plexity, if the case is one of ordinary enterocele; but, if it be con- 
stituted by the omentum alone, the absence of gurgling on reduction, 
and of other characteristic signs, may invest the case with considerable 
obscurity. The treatment in all cases is the same, — to practice the 
taxis, and maintain the displaced viscus in its proper situation while 
labor is in progress, with the object, as we have said, partly of pre- 
venting the possibility of mechanical obstruction, but mainly with the 
view of protecting the displaced parts from injurious pressure. 



XXXV.] VARIOUS TUMORS. 581 

The various tumors which have been described do not, it need 
scarcely be said, embrace all the possible varieties of abnormal growth, 
which may be encountered as impediments to the progress of labor. 
Fibrous, fatty, or encysted growths may spring from any portion of the 
cellular tissue of the pelvis. The direction which these most frequently 
take, is that of the recto-vaginal pouch ; but they have also been ob- 
served in the sides of the canal, and even between the uterus and the 
bladder. To distinguish such abnormal structures from those which 
have their origin in the tissues of the various organs which are situated 
in the pelvis will always be a matter of difficulty, sometimes of impos- 
sibility. Everything will depend upon the mobility and compressibility 
of such tumors, and the result, in many cases, will simply be an in- 
creased difficulty in the passage of the child, the forces of nature ulti- 
mately overcoming the obstacle. 

But, in some cases, the volume and immobility of the tumor may be 
such as to preclude the possibility of any such favorable result; and, 
in that case, we may be forced to adopt such surgical means as may 
with the least risk get rid of the difficulty. If it is a cyst, it will be 
proper, therefore, to evacuate its contents ; and, if solid, its size, shape, 
and the nature of its connection, by adhesion or otherwise, must serve 
as our guides to such operative measures as, on general principles, the 
nature of the case seems to demand. Excision of such tumors is, of 
course, under these circumstances, an operation which is attended with 
peculiar risk: it has been practiced by an incision through the vaginal 
walls; and, in some other cases, with success, by a more extensive 
incision involving the thickness of the perineum. The w T orst cases are 
those in which the size of the tumor, its immobility, and the great 
extent of its adhesions, render such operations impracticable ; and, in 
these nothing will be left to us beyond the more desperate resources of 
operative midwifery. 

Frequent reference has been made to malignant tumors as obstacles 
to delivery. The nature of this fearful class of diseases is such that 
the impediment may have its origin in the bones, ligaments, uterus, 
bladder, rectum, or any conceivable part or structure of the pelvic con- 
tents. Moreover, from a tumor of trifling size, it may attain dimen- 
sions which are only limited by the capacity of the pelvic canal; and 
the tendency of all malignant growths to invade contiguous textures 
frequently places the case in a category peculiar to itself, inasmuch as 
it is impossible to isolate it either for the purpose of removal or dis- 
lodgment. In the ordinary or scirrhous form, the stony hardness of 
the tumor, which is absolutely incapable of distension, the infiltration 
and infection of surrounding tissues, the binding together of the parts, 
the presence of ulceration, and the existence of marked cachexia, will 
generally render diagnosis a matter of no difficulty. 

In the initiatory stage of the disease, the diagnosis will naturally be 
more obscure, and in cauliflower excrescence, and the rarer fungoid 
forms of malignant disease, the symptoms are very different from those 
above indicated, but are still sufficiently characteristic to enable us to 
form a definite opinion as to the nature of the case. From what has 
been said, it will be obvious that no surgical rules can be laid down 



582 OBSTRUCTIONS TO LABOR. [CHAP. 

for the management of cases such as these, whether the tissue primarily 
invaded be the labia, the uterus, or any other portion of the canal. 
The nature of the case, and the extent of the obstruction can alone be 
our guides. Malignant atresia has repeatedly been overcome by 
incision of the diseased structures, with success as regards delivery of 
the child ; but, in those cases in which the disease is extensive, it will 
only remain for us to decide between the forceps and the other more 
serious operations. 



CHAPTEE XXXVI. 

OBSTKUCTIOK DEPENDING OJS" THE STATE OF THE OVUM. 

HYDROCEPHALUS : DIAGNOSIS OF : MANAGEMENT OF SUCH CASES — SPINA BIFIDA — 
OBSTRUCTION FROM ASCITES, HYDROTHORAX, AND DISTENSION OF THE BLAD- 
DER — GASEOUS DISTENSION FROM PUTREFACTION — TUMORS SPRINGING FROM 
THE FCETUS — ANCHYLOSIS OF THE JOINTS, AND INTRA-UTERINE FRACTURE — 
PREMATURE CLOSURE OF THE SUTURES — UNUSUAL DEVELOPMENT OF THE 
FC3TUS — SPECIAL DIFFICULTIES IN PLURAL PREGNANCY: LOCKED TWINS — 
MONSTERS WHICH IMPEDE DELIVERY: THE SIAMESE TWINS, AND OTHER SIMI- 
LAR CASES — SHORTNESS OF THE UMBILICAL CORD AS AN OBSTACLE — DORSAL DIS- 
PLACEMENT OF THE ARM — THICKNESS AND PERSISTENCE OF THE MEMBRANES. 

It not unfrequently happens that, although the maternal parts are, 
in every respect, normal, and the position everything that may be de- 
sired, the relative proportions which should exist between the ovum 
and the canal are disturbed by an abnormal condition of the former. 
The peculiarities in structure which give rise to mechanical obstruction 
of this nature, consist, mainly, of an increase in size, whether of the 
whole foetus or of some of its parts, arising, in one class of cases, from 
faults of development, and in another, from the effects of intra-uterine 
disease. The peculiarities alluded to may affect either the foetus itself 
or some of the other parts of the ovum : no reference is here made to 
malposition of the foetus, a subject which has already received full 
consideration. 

The diseases of the child from which such unfortunate conditions 
spring, are those in which some one of its parts becomes the seat of such 
an increase in size as to constitute an impediment, more or less serious, 
to the progress of labor. Of these the more important are hydroceph- 
alus, fluid distension of the great cavities of the trunk, and tumors 
of various kinds springing from its external surface. Hydrocephalus 
is, of all such affections, not only, as might be expected, the most im- 
portant from a mechanical point of view, but is so also in point of fre- 
quency. One form of this affection, or rather one which has been by 
many writers, erroneously described as such, is an effusion of fluid be- 
neath the scalp or pericranium, and consequently, exterior to the cranial 






XXXVI.] HYDROCEPHALUS. 583 

cavity. Examples of this, which has been termed external hydro- 
cephalus, are very rare, and have usually been found to be associated 
with a general condition of infiltration affecting the whole of the ex- 
ternal tissues of the foetus. It is a condition which usually involves 
the life of the foetus, so that any serious impediment from a child which 
is in all probability putrid need scarcely be anticipated. 

The internal variety, or what is known as true Hydrocephalus, is a 
much more serious as well as a more frequent occurrence, and may 
exist to such an extent as absolutely to preclude the possibility of de- 
livery by the unaided efforts of nature. In this case, the fluid which 
is effused within the cranial cavity, varies greatly in quantity. In those 
instances in which the quantity is small, the difficulties of parturition 
may not be materially augmented, as the compressibility of the head 
is, in consequence of the nature of its contents, relatively increased — a 
condition which obviously tends to facilitate its passage, and compen- 
sates for the actual increase of bulk. Owing to this, indeed, and asso- 
ciated probably with ample pelvic diameters, very large heads have 
been known to pass naturally. In some cases, the head, in consequence 
of the quantity of fluid which is poured out by the morbid process, at- 
tains enormous dimensions. When the disease is slow in its progress, 
the flat bones become developed to a very unusual extent, but when 
more rapid, the deposit of bone does not keep pace with the distension 
of the head, and the latter, under such circumstances, may present itself 
under the form rather of a bag of fluid than of an ordinary cranial pres- 
entation. The rule certainly is that the process of ossification fails to 
overtake that of fluid distension, and a marked characteristic, therefore, 
of hydrocephalic heads is that the sutures and fontanelles are more 
apart than usual. 

When the size of the head is considerable, and the symptoms conse- 
quently well marked, the recognition of hydrocephalus is generally 
easy enough. The presenting part, which in these cases is arrested 
above the brim, is found to be less resistant, and less convex than usual. 
The sutures and fontanelles are, however, to be distinctly felt ; and, if 
we can feel that the former are agape, and the latter of larger size than 
usual, with more or less of a feeling of fluctuation, there will be little 
room for doubt. The existence of a large posterior fontanel le is par- 
ticularly characteristic ; and, if the hand can be fully introduced, the 
great size of the head will be recognized. 

This applies, of course, to those cases only in which the cranium pre- 
sents at the brim. It often happens, however, in such instances, that 
the same reasons which, under ordinary or normal circumstances, cause 
the head to adapt itself to the smaller end of the ovoid cavity of the 
uterus, operate by so determining the presentation, that what is here 
the larger extremity of the foetal oval lies in the fundus of the uterus, 
the pelvic extremity being downwards. The conditions being thus ab- 
sent upon which alone our diagnosis can depend, no suspicion is enter- 
tained as to the nature of the case ; and it is only when, after the head and 
trunk have passed the brim, and the head is there arrested, that suspi- 
cion is awakened, and the existence of hydrocephalus possibly recog- 
nized. For, in such cases, it is by no means an easy matter to make 



584 OBSTRUCTIONS TO LABOR. [CHAP. 

sure of this as it is only a limited portion of the occiput which can be 
reached with the finger j but, if we find the pelvis of average dimen- 
sions, and arc able to recognize a large head with its hones loosely 
articulated, and a trunk and limbs somewhat loss in size (ban usual, we 
shall probably take these (acts as sufficient collectively to warrant a 
confident decision. Another symptom which, when the bead presents, 
has been insisted upon by Blot, is that while the bead is absolutely 
arrested at the brim, the whole body of the foetus is higher relatively to 
the abdominal walls; and, therefore, the pulsations of. the fcetal heart 
may bo recognized as high as, or even higher (ban, the level of the 
umbilicus. 

The nature of the obstruction depends not merely upon the quantity 
of fluid effused within the cranium, but also upon the development of 
the flat bones, and the degree of compression of which the head is sus- 
ceptible. These conditions may, however, with truth be regarded as 
subsidiary t<> another, arising from the manner in which the head 
descends and becomes engaged in the pelvis. A mere bag of water, 
(and the head is sometimes reduced mechanically to this condition) 
may, so long as it remains unruptured, be an impediment as insur- 
mountable above the brim as an absolutely solid mass would be. But, 
if the eon format ion of the parts, and ot her conditions, should permit of 
the engagement of such a tumor, so that its lateral walls are efficiently 
compressed by the pelvic canal, matters are so completely altered, that 
an elongated oval, containing an equal bulk of fluid, may pass through 
the passage, while one which is spheroidal, or, with reference to the 
aperture of the brim, transversely ovoid, cannot even enter. It is, no 
doubt, on this principle that those cases have occurred, of which we 
read, where a child has been born alive, with a head measuring, in its 
circumference, twenty-two or twenty-four inches, whereas (he normal 
Standard is, on an average, about thirteen inches and a half. 

While recognizing these facts, however, (he operator must beware of 
trusting to such a result, unless lie finds that die pelvis is ample, and 
the cephalic tumor is pointing downwards, thus giving indications of 
moulding itself to the pelvic canal. There are, perhaps, few contin* 
gencies in the practice; of midwifery in which a careful and early 
diagnosis is of greater importance than here; for, however revolting 
the operation of craniotomy may be to a well-regulated mind, the more 
fearful risk of delay must be; from the first, admitted into our calcula- 
tion. In seventy cases collected by Dr. Thomas Keith, rupture of the 
uterus occurred in so large a proportion as sixteen ; while, in every one 
of the five cases recorded by Dr. Robert Lee, in his Clinioal Mid' 
wifery, the mother was lost either from rupture of the uterus, or 
inflammation of the organ, facts which — independently of many others. 
corroborating the conclusion — point significantly to the danger (hat, in 
such eases, attends delay. 

The indications of treatment are, from one point of view, sufficiently 
obvious; but our action will, in no small measure, be swayed by the 
presence or absence of symptoms indicating the vitality of the child. 
If the child is dead, we do not require to wait for absolute certainty of 
diagnosis. Evidence of serious obstruction is all that, in such a case, 



XXXVI.] HYDROCEPHALUS. 585 

we would think necessary to warrant us in perforating and giving vent 
to the fluid which is pent up within the cranium. But, when the child 
still lives, the responsibility which attaches to the operation is greatly 
increased, and- the error which, in such cases, is most likely to be com- 
mitted is that the operator may wait until the mother has become 
exhausted or the child has died ; whereas, he ought to have sooner 
recognized the fact that the passage of a living or viable child was 
impossible, and have acted upon the principles which we have already 
laid down as applicable generally to cases of destructive or sacrificial 
midwifery. The immediate effect of craniotomy, in hydrocephalus, 
generally is to reduce the bulk of the head, by the escape of a large 
amount of fluid, to an extent much greater than obtains when perfora- 
tion is practiced under other circumstances. It may happen, as in some 
recorded cases, that the operation, as well as the diagnosis, may be com- 
plicated by the coexistence of what has been described as " external," 
along with internal hydrocephalus, when it may be necessary to evac- 
uate the external accumulation of fluid before piercing the cranium. 
To such an extent does the distension sometimes occur that several 
pints of fluid have been removed by simple perforation, when collapse 
of the cranium takes place, so as to permit of the expulsion of the head 
under the influence of the natural efforts. 

It has happened that, after perforation, and evacuation of the serum 
contained within the cranium, the child has been born alive; so that, 
although the chances of a child surviving under such circumstanses 
may be considered as extremely small, it has been urged by Cazeaux 
and others that the operation should be so performed as, if possible, to 
to prevent laceration of the cerebral structures, and the inevitable 
sacrifice of the child which must thus ensue. It has been suggested, 
therefore, that, on this account, the ordinary perforating apparatus 
should be rejected, and a simple puncture effected, by means of a 
trocar or guarded bistoury, sufficient to penetrate the membranes 
through a fontanelle or suture, and nothing more. From what has 
already been said, it will be apparent that, in the minor cases, any 
mode of procedure which may promote lateral compression of the head 
may, with possible advantage, be adopted in preference to craniotomy. 
With this in view, therefore, it is usual and proper to attempt delivery, 
in the first instance, by means of the forceps, when the compressing 
power of that instrument may be employed to a somewhat greater 
extent than is usual ; but, if this fails, and the circumstances of the case 
are otherwise such as to preclude the hope of expulsion by the unaided 
efforts of nature, the more serious operation should be practiced without 
delay. 

If the difficulty should arise in a presentation of the pelvic extrem- 
ity, — which occurs, according to Scanzoni, in one in five of all cases of 
hydrocephalus, — the operation is one which cannot be performed with 
the same facility. Various modes of procedure have been suggested as 
applicable to such instances. It has been found possible, for example, 
to reach the cranial cavity through the mouth, by piercing the base of 
the skull through the vault of the palate ; and, in other cases, it has 
been successfully practiced through the orbit ; but what, in such cases, 



586 OBSTRUCTIONS TO LABOR. [CHAP. 

we would recommend, in preference to either of these methods, would 
be direct perforation behind the ear, should it be possible to reach that 
part of the cranium for the purpose. 

It has sometimes happened that the tumors which are connected 
with osseous deficiency of the cranium or vertebral column, and which 
are known to the surgeon as Crania Bifida, or Spina Bifida, have at- 
tained such dimensions as to prove an obstacle to delivery; in which 
case it may be necessary to perforate the tumor and evacuate the fluid 
which it contains. Effusions into the other great serous cavities of the 
body, although less frequent in their occurrence than hydrocephalus, 
render delivery equally impossible. In Ascites, the development of 
the abdomen is sometimes enormous, and is revealed by the fluctuation 
as well as by the size. The only affection of a similar kind with which 
we might possibly confound it, is distension of the bladder, which, 
when the urethra is impermeable, may give rise to a tumor of great 
size, which may require tapping equally with the peritoneal effusion. 
The description of such a case was communicated by M. Depaul to the 
Aeademie de Medecine ; and this, it may here be observed, is, along 
with other similar cases, one of the most important points of evidence 
upon which physiologists rely in supposing that the urine of the foetus 
is naturally evacuated into the amnionic cavity. 

When the peritoneum of the child is distended with fluid, so as to 
prevent its passage, that cavity must be pierced by a trocar, and the 
fluid which it contains drained away by the canula. Hydrothorax is 
still less frequent in its occurrence. It is indicated by an enlargement 
of the thoracic region and intercostal bulging, and may require punc- 
tures to be practiced between the ribs, with precisely the same object 
as in the other case. In all these cases, the operation of perforation 
should be so performed as to avoid injuring the internal organs ; for 
not only would this entail unnecessary mutilation, but might defeat our 
object, by preventing the escape of the fluid. The development within 
the body, as a result of putrefaction, of enormous quantities of gas, is a 
fact familiar to the medical jurist, and one which may take place within 
the womb as well as under other circumstances. In some rare in- 
stances, it has occurred that, in consequence of this, severe laceration 
has been inflicted, with a fatal result ; and, in other cases, labor has 
been terminated in consequence of a rupture giving issue to the pent- 
up gas. No hesitation should, in such a case, deter the operator, as 
the evidence of the child's death will be otherwise complete, and he is 
bound to act so as to protect the mother from risk. 

Tumors of various kinds may spring from the surface of the foetus, 
or be developed in connection with some of the internal organs, and 
may, by attaining unusual size, render labor impossible of natural 
termination. Tumors have, for example, been observed, which had 
their origin in the liver or the kidneys, enlarging the trunk to an 
enormous extent, so as absolutely to prevent its passage, and render 
indispensable the operation of embryulcia, in the course of which it 
has been found necessary to break up the tumor, and remove it piece- 
meal before we can complete the delivery. Another rare condition of 
the foetus, which may be a very serious obstacle, is anchylosis of the 



XXXVI.] PLURAL PREGNANCY. 587 

articulations, and the same may be said of those cases in which there has 
been intra-uterine fracture as the result of violence, the limbs having 
united at an angle. It is difficult to say what, under such circumstances, 
should be done, if the condition has been recognized before birth ; but, 
in so far as anchylosis is concerned, we may assume that the joints will 
probably be united while the limbs are flexed upon the body in the usual 
attitude of the foetus, and that the conditions are therefore not altogether 
unfavorable to the natural termination of labor. A more serious impedi- 
ment has been in some instances found to arise from premature closure 
of the sutures and fontanelles. This, in a perfectly normal condition 
of the parts otherwise, may give rise to great delay, if not impaction, 
by its being impossible for the head to adapt itself in any way to the 
shape of the passage; and, as Dr. Tyler Smith has observed, the dan- 
gers of such a condition are not limited to the mechanical hindrance to 
delivery, but may be looked upon as an extremely probable, if not 
certain cause of idiocy, by preventing the development of the brain. 

The child sometimes, even when not retained within the uterus 
beyond the ordinary period of gestation, attains a size so greatly in 
excess of the ordinary standard, as to cause a very difficult or danger- 
ous labor. If we take, as has already been stated in round numbers, 
the average weight of the fully developed foetus as seven pounds and a 
quarter, we are not astonished when we find in practice, that when it 
approaches twelve pounds the labor is, unless the maternal parts are 
of unusual capacity, a slow and painful one. But, when it reaches 
fourteen, fifteen, or nearly eighteen pounds (as in one well-known and 
authentic case already cited) it is difficult to conceive how by any pos- 
sibility such a child could pass. If, however, we look closely at chil- 
dren which are much above the average, it will be observed that the 
increase in weight is to a great extent due to the development of fat 
beneath the skin, so that it is the trunk and limbs, rather than the 
cranium, which are increased in size, and it is on this account that we 
find the powers of nature sufficient for the expulsion of the child. If 
the increase of bulk has been the result of a protracted sojourn of the 
foetus in the womb, the case will probably be more serious in its nature ; 
and, certainly, in all such, we may be sure that the maternal as well 
as the foetal mortality will be increased relatively to the size of the 
child. Statistics, indeed, tell us that this is the case, even as regards 
the comparatively trifling difference which exists between the male and 
female cranium. It is, however, very rare that, in the absence of pelvic 
deformity, cases of unusual foetal development may not be delivered 
by the forceps or turning, which we may term the minor operations of 
midwifery. 

The occurrence of Plural Pregnancy may in various ways give rise 
to difficulty, and even to serious obstruction. In the case of multiple 
pregnancy, the products of conception may be disposed in almost any 
manner compatible with the limits and mechanical conditions of the 
uterus ; but it does not appear that any great difficulty has been met 
with, in these instances, unless one or more of the children has been 
in a faulty position. The same remark applies to twin pregnancy. In 
the latter, the two children are most frequently observed to occupy 



588 OBSTRUCTIONS TO LABOR. [CHAP. 

each a side of the womb, with the cephalic extremities downwards, and 
one head somewhat in advance of the other. In a very considerable 
number, the head of one child and the breech of the other present; 
while, in rarer instances, the feet of both may be downwards, or one 
or both may lie transversely in the womb. 

In plural pregnancy the uterus, no doubt, acts at a certain mechanical 
disadvantage, inasmuch as its propulsive force is communicated to the 
foetus which is lowest in the uterus — not directly, as in single preg- 
nancy, but indirectly through the bodies of the others. But, as has 
been well observed, this disadvantage is usually compensated for by 
the comparatively smaller size of the children. The cases where delay 
is most likely to occur are those in which the breech of the first child 
is the presenting part ; and, as this descends, the difficulties, as in 
ordinary cases, will be greatly increased by any unusual resistance at 
the outlet. And then, after the passage of the breech, the descent and 
birth of the head — a matter of difficulty, as we have seen, even in pres- 
entations of the breech in single pregnancy — is here so much more so 
that, unless the accoucheur was at hand to afford the assistance of his 
art, that child, at least, would be almost certainly sacrificed. 

As has already been observed in an early chapter, when the subject 
of plural pregnancy was under discussion, there is very often a period 
of considerable delay after the birth of the first child. This is probably 
due, in many instances at least, to uterine exhaustion ; and the pause 
which then ensues is a perfectly natural condition, which we should 
rather encourage, as it enables nature to recruit her exhausted forces, 
and thus bring them into renewed activity when the period arises for 
the expulsion of the remaining contents of the uterus. The recommen- 
dations, therefore, which are given by some authorities as to the cir- 
cumstances which warrant, in such cases, operative interference, should 
be received with great caution, and only acted upon when the condi- 
tions are such as to indicate beyond the possibility of doubt that it is 
proper to aid or precipitate labor in any way. 

But the most serious mechanical difficulty which may arise in the 
course of labor in plural pregnancy, is what has been described in the 
case of twin pregnancy as "locked twins." When the membranes are, 
as has previously been shown (see Figs. 91 and 92). so arranged that 
each child lies in its own complete sac, the expulsive forces act, even 
under such mechanical disadvantages, so as to expel one child first, and 
to leave the other still enveloped in its own amnion. The first birth 
thus takes place without any particular difficulty. But, if they are 
inclosed in one amnionic cavity, the parts of the two may fall into such 
a position as to make delivery a matter of the greatest possible diffi- 
culty. The most common form of locking is when the first child pre- 
sents by the breech, and passes downwards up to a certain point without 
impediment ; but when serious obstruction occurs, and we are thus led 
to make a more particular examination, it is discovered that the descent 
of the head is obstructed by the presence in the pelvic cavity of the 
head of the second child, which has caused the chins to be so hitched 
together that the completion of the first birth is rendered a matter of 
impossibility, unless the twins are small or the pelvis large. If, under 



XXXVI.] LOCKED TWINS. 589 

such circumstances, we pull upon the body of the partially born child, 
we only make matters worse by locking them more firmly together. 
In some cases, when the condition of the parts is such as to admit of 
it, it may be possible, by pressing back the heads in the direction of 
the uterus, to unlock them, and thus to permit of their descent singly. 
But, if this endeavor should fail, it will become evident that the only 
way to disengage them is to break up the compound wedge and so 
admit of the passage of one or other of the children. 

This may be effected in two ways, as has been well demonstrated by 
Dr. Barnes; either by decapitating the first child, which we have the 
least chance of saving owing to the pressure which is being exercised 
on its umbilical cord, or by perforating the head of the second child, 
so as to admit of the passage of the first. In the first case, the body 
which occupies the vagina will at once pass, and its head receding will 
admit of delivery of the second child by the forceps; and in the second, 
which is only justifiable when we have reason to believe that the other 
child is dead, we allow the perforated head to be flattened to such an 
extent as to admit of the passage of the head of the first, through the 
diameters which the operation has succeeded in reducing. This latter 
plan has the obvious advantage over the former that the difficulty of 
extracting the severed head is thereby avoided. 

There is another form of locking, in which both of the twins present — 
as is most frequently the case — by the head. The first head passes in 
this case without difficulty into the pelvis, but the head of the second, 
descending along with the trunk of the first, prevents further progress 
by presenting the bulk of a head and a thorax simultaneously at the 
brim. The mechanical management of such a case as this may be a 
matter of even greater difficulty than the former. Perforation of the 
head which is within reach can obviously do no good, so that it is only 
by guiding the perforator upwards to the second head, and reducing 
its bulk in the usual way, that the operation may be, with any hope of 
success, adopted. In such cases, as has been shown by the experience 
of Dr. Graham Weir and others, it may be possible by dexterous 
manipulation to obviate the serious difficulties which exist. It has 
been found practicable in this way to extract by the forceps the child 
which originally presented while the head of the other was pushed 
aside by an assistant. External manipulation has also succeeded in 
skilful hands in forcing onwards the head which was situated highest 
in the pelvis, and thus causing it to take precedence of that which 
originally presented. All cases of locked twins are, however, serious 
complications, and are therefore with justice looked upon as among 
those dangers against which the operator should be prepared. 

The first or second child may present in a preternatural manner, — 
by the shoulder, for example, as has before been explained — and in 
such a case, we have to beware of the mistake, which has been com- 
mitted, of seizing the wrong foot or feet when the hand is introduced 
for the purpose of turning ; or it may happen, as in a case narrated by 
Madame Lachapelle, that when turning has been successfully effected, 
and the breech extracted, locking by the chins is the perplexing result. 
It is to be borne in mind that, in plural pregnancy, there is a greater 



590 OBSTRUCTIONS TO LABOR. [CHAP. 

risk of haemorrhage, owing to the extent of surface to which the pla- 
centa is attached. And, in cases in which there is an inosculation of 
the cords, there is, at an earlier stage, another special risk, if we leave 
the placental portion of the severed cord untied. 

Various forms of Monstrosity give rise to difficulty in the course of 
labor, and in extreme cases it is only possible to complete delivery by 
embryotomy or the Csesarian Section. We have here, of course, 
nothing to do with such departments of teratology as are illustrated by 
acephalic or anencephalic monsters; and still less with those which are 
anopic or cyclopic, as such conditions present no mechanical obstacle 
whatever. The many different forms of ectopy present, as a rule, little 
or no difficulty; but in the more complete form, as in a case figured by 
Vrolik, the whole of the thoracic and abdominal viscera are external to 
the child, and may impede its passage. It has been observed, in another 
form of monstrosity, that the liver projecting through the unclosed um- 
bilicus (Exomphalos) has, by its augmented size, caused a serious impedi- 
ment, which might well be expected to bar the progress of ordinary labor. 

The forms of monstrosity which are, from the point of view of me- 
chanical obstruction, the most serious, are those in which the two chil- 
dren in a twin pregnancy become fused together to a greater or less 
extent, the union or fusion being anatomically symmetrical. Infinite 
as the varieties of such cases are, this rule is never violated, and is 
indeed the only possible method of which the laws which regulate 
development can admit. Thus, we have union of sacrum to sacrum, 
occiput to occiput, or abdomen to abdomen ; but never sacrum to 
occiput, or abdomen to sacrum. There may be one perfect trunk with 
two heads, as shown in the annexed cut, which closely resembles a 
case of this kind, which we had an opportunity of seeing with Dr. 
George Mather ; but the union may be even higher than the cervical 
vertebra?, when we have more or less fusion of the crania. In such 
a case as the one here represented, in which the size of the various 
parts was rather more than is usual at the full time, a mere glance will 
suffice to show, not only that labor must necessarily be impeded, but 
that it is scarcely possible, in a normal condition of the parts as regards 
size, that a natural termination should take place. 

In a case which has been described by Meigs, one head descended 
first and was delivered. It then became fixed under the subpubic 
angle, and the ultimate process of delivery was precisely similar to what 
takes place in the spontaneous expulsion of a transverse presentation, 
the trunk, breech, lower limbs, and, lastly, the second head, passing 
through the external parts. In the case to which reference was made 
above, delivery was accomplished with the greatest possible difficulty. 
It was a primiparous case, and the breech was the presenting part, 
everything going on well until the heads entered the pelvis, when com- 
plete arrest took place. The crotchet failed completely, and as Dr. 
Mather thought that the head was too high to use the perforator with 
safety, he attempted, by means of steady traction, to bring it more 
w T ithin reach, when, to his astonishment, two heads descended, situated 
obliquely with reference to each other, in the pelvis, so that the one 
was a little in advance of the other. In this way, and after long- 



XXXVI.] 



MONSTROSITY. 



591 



protracted efforts, the heads, which were quite the average size, passed. 
The pelvis was, as might have been expected, a capacious one; but even 
this does not make the case less interesting. The mode of delivery 
described by Meigs is generally supposed to be the only possible way 
in which such a child can be born without perforation or decapitation ; 
but the case above given, which is extremely rare, if not unique, shows 
that if the other be the rule, it has at least, like many other rules, 
exceptions. 

In that class of cases in which there is one head and a double condi- 
tion of the lower parts of the body (Janiceps), the difficulty is not likely 
to be so great, as it is much more conceivable that two pelves could be 
sufficiently pressed together during their descent as to admit of their 



Fig. 195. 



Fig. 196. 





Double-headed monster. 



Double monster. 



simultaneous passage through the pelvis of the mother. The monster 
here shown, from one which was described by Dr. J. G. Walter, has 
three legs and four arms. Complete fusion of the pelves was found on 
examination after death to have occurred, and there was also union of 
the ensiform cartilages. On first sight it may appear that delivery, in 
such a case, would be even more difficult than of the ordinary two- 
headed monster; but a little consideration will show that the possibility 
of one head at a time passing along the pelvis, gets rid of the greatest 
difficulty which attaches to this variety. The probability of a trans- 
verse presentation in such a case is, however, very strong ; and this, of 
course, would be a most unfortunate circumstance, as turning and 
bringing down the feet would inevitably bring the heads together, and 
thus make matters worse than ever. 



592 OBSTRUCTIONS TO LABOR. [CHAP. 

It has occasionally happened that twins, more or less completely 
united or fused together, have been born alive, and have even attained 
maturity. In the most familiar instance of this kind — that of the well- 
known Siamese twins — there was a mere band of union; but it is indeed 
difficult, in regard to this and other similar cases, to conceive even the 
possibility of birth, unless after mutilation or putrefaction ; in fact, we 
can only suppose, in reference to such, that the maternal pelvis has 
been of unusual capacity, that labor has occurred prematurely, or that 
both of these conditions have been combined. Another comparatively 
rare form of monstrosity has been mentioned under "Twin Pregnancy" 
as monstrosity by inclusion; and, in this case, the tumor of the perineum, 
which contains the foetus in fostu, may be a serious obstacle. It will 
readily be understood — and the more so as they are of extremely rare 
occurrence — that such cases may cause great perplexity to the accoucheur, 
and, whether the diagnosis is accurately formed or not, cannot fail to 
be a very serious barrier to delivery. So various, however, are the 
forms under which monstrosities present themselves, that it is impos- 
sible to lay down any general rules which might serve for the guidance 
of the practitioner. In a considerable number of cases, it has been 
found necessary to decapitate, eviscerate, and otherwise mutilate one or 
both of the united twins or repeated parts before it has been possible to 
relieve the woman of the contents of her womb. Care must, it need 
scarcely be added, betaken, not only to insure correctness of diagnosis, 
but also not to operate rashly, for there can be no doubt that we are 
morally bound to consider the life of monsters as scrupulously as that 
of the fetus in normal pregnancy. 

Shortness of the umbilical cord is generally mentioned in systematic 
works as a possible mechanical hindrance to delivery. It is certain, how- 
ever, that such an occurrence is extremely rare. We do not mean to 
assert that the cord is not occasionally short, but merely that this effect 
of shortness is not one which is likely often to take place. Cases do 
occasionally occur, in which the actual length of the funis does not ex- 
ceed two or three inches, a condition which, if the placenta is normally 
situated, must imply delay in delivery, rupture of the cord, premature 
separation of the placenta, or inversion of the uterus. Some have 
denied that any impediment whatever is in this way likely to arise; 
but the evidence which has been advanced in favor of the contrary view 
seems pretty clearly to show that in cases of protracted labor, which 
have only terminated after rupture of the cord, the probable cause of 
the delay must have been the extreme shortness of the link which 
bound the foetus to its utero-placental attachment. 

What is certainly of more frequent occurrence than actual shortness 
of the cord is — what has mechanically precisely the same effect — coil- 
ing of the cord round the child. In such cases, there is usually not 
only no shortening of the cord, but an undue-length of it, which is the 
original cause of the coiling which takes place round the neck more fre- 
quently than round any other part of the foetus. This artificial short- 
ening is, we believe, of more frequent occurrence than is usually sup- 
posed ; and every practitioner knows that few things are more common 
in practice than to find one, two, or more coils of the funis round the 



XXXVI.] DORSAL DISPLACEMENT OF ARM. 593 

neck of the child. The exact stage of delivery at which arrestment 
from this cause is most likely to occur, depends upon the length, or the 
length exclusive of coils, of the cord ; but, as a rule, it would appear 
that it is seldom that much inconvenience is complained of until the 
stage of expulsion approaches, when, for the first time, the cord is put 
upon the stretch, and pain is, probably, to some extent complained of 
in the region of the uterus. It has been stated, as a symptom during 
labor of shortness of the cord, that if the placenta is attached at its 
usual site, a depression of the fundus occurs at every pain, the rounded 
form being restored in the interval. That such an occurrence may take 
place, it would be impossible to deny ; but it seems to us pretty clear 
that this is one of the instances, of which illustrations are too frequent 
in medical literature, wdiere what we may call a theoretical symptom 
is set down as a real or practical one. 

It has frequently been observed, when the cord was coiled round the 
neck of the child, that progress was for the first time arrested during 
or after the birth of the head. This has probably to some extent, led 
to the routine practice of disengaging the coils as soon as their presence 
is detected — although the main cause undoubtedly is a dread of suffo- 
cation of the child by pressure on the respiratory passages. It has in 
some instances been found necessary, when the cause of the obstruction 
was evident, to cut the cord, a course of procedure which must recom- 
mend itself to the operator when the nature of the case is obvious. 
Caution should of course be exercised to prevent haemorrhage from the 
cut vessels, by placing a ligature speedily on the umbilical side of the 
section ; but it has been pointed out that a slight discharge is rather 
favorable in its effect than otherwise when asphyxia is threatened, a 
condition which may very probably be found to exist, along with the 
semi-apoplectic condition depending upon interruption to the circula- 
tion in the great vessels of the neck. In breech presentation, or after 
the performance of podalic version, the cord sometimes is found sur- 
rounding the trunk or entangled among the limbs, wdience it will be 
proper to disengage it if possible, and, if this cannot be effected, to cut 
it, rather than run the risk of obstruction in what, for the child at least, 
is always a critical labor. After such cases, it is proper to introduce 
the hand into the vagina to ascertain that there is no inversion of the 
uterus, unless the. state of the organ as observed through the abdomi- 
nal walls, is in all respects satisfactory. 

A rare and curious cause of obstructed labor has been shown by Sir 
James Simpson to arise from dorsal displacement of the arm. This 
may occur either in pelvic or cephalic presentations. In the former 
case, which is more frequent, it is probably due, as Barnes shows, to 
an improper and imprudent dragging upon the limbs, the tendency of 
which is, as has formerly been shown, to allow the arm to pass up 
alongside of the head. If one or other arm should, in this process, get 
behind the head — as is still more likely to occur in unskilful turning — 
it is not difficult to understand how the arm may get behind the neck 
and beneath the occiput, and thus constitute an impediment of a very 
serious character, the limb being so placed that its reposition is a matter 
of no inconsiderable difficulty. The arm will, in such cases, generally 

38 



594 OBSTRUCTIONS TO LABOR. [CHAP. 

lie against the symphysis pubis, and it will therefore only be practi- 
cable to dislodge it, if we can succeed in pushing the parts upwards, so as 
to leave sufficient room, between the occiput and the upper part of the 
symphysis, to admit of such manipulation as may effect our object. In 
Simpson's case, the presentation was one of the head, in which the arm 
had in some peculiar way which it is difficult to understand got on to 
the nape of the neck, and was thrown transversely across the pelvis. 
The course suggested by him for the management of such cases is to 
bring the arm clown by the side of the head, as its complete reposition 
above the brim would probably be impossible, and allow labor to go on 
in this way, the presentation now being an ordinary head and arm case ; 
but we are impressed with the idea that the mode of procedure adopted 
by Dr. Jardine Murray in similar circumstances, which simply con- 
sisted in turning, meets much more fully the difficulties of the case. 

There is but one other condition arising from the state of the ovum 
to which we think it necessary here to refer. This is unusual thick- 
ness and resistance of the membranes, which, sometimes, while things 
are otherwise going on favorably under efficient uterine contraction, 
absolutely stops the progress of the labor. It is needless to recapitu- 
late what has already been said as to the management of the mem- 
branes ; the only important point being that, before we decide on rup- 
turing them, which will at once bring the difficulty to an end, we 
should be sure that the proper function of the membranes has been 
effected in producing dilatation of the os. No danger will accrue to 
the child, so long as the presence of the liquor amnii protects it from 
injurious pressure. 



CHAPTEK XXXVII. 

UTERINE INERTIA AND PRECIPITATE LABOR. 

IRREGULARITIES IN THE PROGRESS OF LABOR: OFTEN DUE TO INTESTINAL DE- 
RANGEMENT — INERTIA : INFLUENCE OF TEMPERAMENT, CLIMATE, AGE, EMO- 
TION, EXCESSIVE DISTENSION, PREMATURE RUPTURE OF THE MEMBRANES, ETC. 
— INFLUENCE OF IRREGULAR UTERINE ACTION : UTERINE TETANUS — WIGAND'S 
CLASSIFICATION: DIFFERENT GRADES AND VARIETIES OF INERTIA — TREAT- 
MENT OF INERTIA: IF FROM OVER-DISTENSION OR DISPLACEMENT OF THE 
UTERUS : IF FROM INTESTINAL DERANGEMENT — VARIOUS MODES OF EXCITING 
REFLEX UTERINE ENERGY — STIMULANTS AS A RULE TO BE AVOIDED — USE OF 
THE FORCEPS IN INERTIA — ERGOT: ITS NATURAL HISTORY, AND PHYSIOLOGI- 
CAL EFFECTS : RULES FOR ITS USE IN MIDWIFERY — OTHER OXYTOXIC AGENTS — 
PRECIPITATE LABOR: CAUSES OBSCURE: APPARENT CONNECTION WITH MEN- 
STRUAL EXCITEMENT — LABOR MAY BE PRECIPITATE FROM DEFICIENT RESIST- 
ANCE — DANGER OF RUPTURE AND LACERATION OF THE UTERUS — TENDENCY 
TO POST-PARTUM HEMORRHAGE — TREATMENT: EMPTY BOWELS: OPIUM: 
SOURCES OF REFLEX IRRITATION TO BE CAREFULLY AVOIDED. 

In no two cases of labor is the course of the process precisely similar, 
although the vast majority are from first to last perfectly normal. 



XXXVII.] UTERINE INERTIA. 595 

Nothing is more familiar to the accoucheur than the sudden and un- 
locked for changes which occur in the course of an ordinary case. In 
one instance, the tardy and inefficient progress which has characterized 
it during many tedious hours gives place, without any very obvious 
reasons, to efficient and even violent action, which brings the act to a 
precipitate termination ; while, in another, the safe and steady progress 
which has led us confidently to anticipate a speedy issue of the case, is 
provokingly interrupted by a failure of expulsive power — and that, too, 
not unfrequently, when the second stage of labor is nearly at an end. 
Such occurrences as these are generally of no great importance, and 
resolve themselves most frequently into a trial of patience, or a mo- 
ment of hurry and excitement ; but cases do now and again occur, in 
which a failure of action, or violence of propulsive force, demands 
prompt and energetic treatment. 

It* has very frequently been observed that, in these matters, much 
depends upon the temperament and constitution of the mother ; so 
that, in members of the same family, in persons of similar temperament 
or constitutional power, and to some extent in those of similar social 
position, there will often be observed a certain resemblance in the char- 
acter and progress of the labor. In some cases, in which the balance 
between pow T er and resistance is in any way disturbed, it would almost 
appear as if nature availed herself of some special compensating condi- 
tion which the exigencies of the case had called into play. The woman, 
for example, whose health has been impaired by chronic disease,, or in 
whom the constitutional vigor and tone are naturally feeble, has as a 
rule comparatively weak uterine action, and alw T ays deficient voluntary 
force ; but yet the labor runs a normal course, for the want of tone in 
nerve and fibre favors relaxation of the parts, and thus, proportionately 
and in a compensatory manner, diminishes the resistance. In women, 
moreover, of this temperament, the anatomical peculiarities of the sex 
are generally well marked, and the ample and shallow pelvis thus 
offers a comparatively trifling resistance to the passage of the child. 
If, however, we contrast with this, the tall, vigorous and muscular 
woman, we find that in the latter there is a very general tendency to 
the male type of pelvis, involving a tardy passage of the child through 
the pelvic canal. May we not infer that it is in some degree in com- 
pensation for this that she is furnished with muscles so powerful, and 
constitutional vigor so marked, to enable her to overcome the greater 
resistance which in a feebler frame would constitute an insurmountable 
barrier. 

There are many morbid conditions which exercise an influence more 
or less marked on the progress of parturition, to which we have had 
occasion more particularly to refer. We may here mention one cause, 
in regard to which no doubt can possibly be entertained, as leading 
both to tardy and precipitate action on the part of the expelling powers. 
This is the condition of the intestinal canal, any irritation of which 
may not only excite powerful reflex contraction, but may cause irregu- 
lar uterine action, and in other cases may arrest it altogether ; this being 
one of many reasons wdiy tardy and precipitate labors are ahvays con- 
sidered together. An attentive observation, from a physiological point 



596 UTERINE INERTIA. [CHAP. 

of view, of the phenomena which accompany parturition, and more 
particularly of the nervi-motor action of the uterus, will suffice clearly 
to show that there are many different ways whereby the forces upon 
which the act of birth depends may be disturbed or thrown out of gear, 
with the result, in one class of cases, of a labor which is too rapid to 
be safe, and, in another, of an arrest in the process which may prove a 
source of danger to the mother as well as to the child. It is, indeed, 
upon a correct appreciation of the physiological phenomena referred to 
that a sound and judicious treatment can alone be based. 

Inert Labor. — It will be inferred from what has just been said that, 
in some constitutions, there is a natural tendency to tedious labor by 
reason of a deficiency in the expelling power. Within certain reason- 
able limits, this calls for no treatment, and is attended with no risk • 
but when these limits are exceeded, the case is to be considered as 
abnormal. Besides general debility, from whatever cause arising, there 
are other conditions which have been observed to increase the liability 
to inefficient uterine and expulsive action. Thus, climate and season 
exercise an influence which, although far from uniform, is sometimes 
obvious, the relaxing effect of a high temperature, in those instances, 
enfeebling the nervous and muscular tone ; and it has even been stated 
that the result of long residence in the tropics has a permanently ener- 
vating effect, which may be manifested subsequently in temperate lati- 
tudes. Another cause is sometimes found to exist in the age of the 
woman, and in cases of precocious pregnancy this is occasionally very 
distinct. In women, again, who become pregnant for the first time in 
advanced life, it is well known that labor, as a rule, is tardy ; and, 
although the idea usually entertained is that this is due mainly to in- 
creased anatomical resistance, there can be no doubt that, in a certain 
proportion of cases, it depends upon deficient force. 

In those who have borne many children in rapid succession, the 
action of the uterus is often found to become enfeebled towards the 
close of the childbearing epoch, probably because the organ has not 
had sufficient time for rest, and for the gradual development of those 
structural changes which succeed delivery, during and after the period 
of involution. The influence of emotional causes, although marked, is 
generally temporary ; as is often seen on the arrival of the accoucheur, 
when it arises from fear. Any sudden alarm, startling intelligence, or 
anything which may give rise to sudden emotion, may produce precisely 
the same effect; and, although, as a rule, the uterus in such cases will, 
after an uncertain interval, resume its function, it occasionally happens 
that the pause is so long, or occurs at such a critical period in the labor, 
that it is necessary to have recourse to art to expedite or complete the 
delivery. The various displacements of the uterus, which act by alter- 
ing the axis of expulsion, are often considered under this head; but 
that which is a purely mechanical cause of delay, has already been 
referred to in a previous chapter. What is here implied by inert labor, 
has reference, almost exclusively, to a faulty condition of the expulsive 
forces, in which they are abnormally feeble and inefficient; and this 
feebleness of contraction may either exist throughout the whole period 
of labor, or may come on, more or less abruptly, in the course of a case 






XXXVII.] CAUSES. 597 

which had, up to that time, progressed in a manner leaving nothing to 
be desired. 

The Causes upon which a failure of uterine action depends embrace, 
in addition to those above mentioned, certain conditions of the parts, 
more or less strictly morbid. To these attention must be given, as it 
is manifest that a mere routine treatment, adopted without an intelli- 
gent reference to the circumstances of the case, must necessarily often 
fail of its object, and may sometimes only tend to make matters worse. 
Excessive distension of the uterus, by thinning the walls or the organ 
beyond ordinary limits, is one of the conditions to which we refer. The 
effect of dropsy of the amnion, for example, may in this way interfere 
with the due action of the organ ; and, in such a case, less good will 
be derived from the exhibition of agents which excite the uterus to 
contract than from rupturing the membranes, and thus allowing the 
uterine wall to come into contact with the surface of the child, when it 
will in all probability be roused to active energy. 

The death of the child was believed by Baudelocque to weaken ma- 
terially the uterine contractions ; but Dubois asserts, and modern 
accoucheurs generally agree with him, that when the woman is in good 
health, the death of the child exercises no influence whatever, in the 
way of enfeebling uterine action, and that if it sometimes happens that 
labor goes on more slowly when the child has ceased to live, this is 
to be accounted for by the fact that the death of the child is probably 
the result of some disease of which the mother has been the subject, 
and that, consequently, her forces have been already weakened. The 
premature rupture of the membranes, and consequent discharge of the 
waters, very generally causes a tardy labor, but this operates chiefly in 
the first stage, and is mainly due to want of the mechanical dilating 
power of the bag of membranes. Inefficient uterine action has often 
been observed to be associated with undoubted morbid conditions of 
the organ. Among these may be mentioned, rheumatism, gout, and 
neuralgia ; and, in addition, congestion and inflammation of the uterus. 
In so far as congestion and inflammation are concerned, while their 
occasional existence cannot be disputed, there can, we imagine, be little 
doubt that the older writers greatly exaggerated their importance and 
frequency, as an excuse for the never-failing remedy of the lancet. A 
morbid condition, however, of the uterine fibre, depending upon some 
form of uterine inflammation, is a possible, and we would venture to 
say a probable, cause of some of the most complete cases of uterine 
inertia. 

A distended bladder or rectum may, in addition to the mechanical 
impediment which it constitutes, act injuriously in arresting uterine 
action ; and it has been observed, in those cases in which pressure on 
the sacral nerves causes cramps in the lower limbs, and the excessive 
agony to which these give rise, that the effect on the uterus is to weaken 
and not to increase its action. Several cases of this kind are cited by 
Meigs. 

Another effect which is occasionally produced is irregular action, in 
which the whole of the organ is not symmetrically contracted. Irregu- 
lar contractions, as we have already seen, give rise to retention of the 



598 UTERINE INERTIA. [CHAP. 

placenta, hour-glass contraction, and inversion of the uterus ; and, in 
like manner, they necessarily occasion pains, which are inefficient, in- 
asmuch as they do not act upon the whole circumference of the ovum. 
In such cases, the pains are more irregular in their occurrence, and the 
suffering, which is severe, is referred at one time to one part of the 
uterus, and again to another. Sometimes, the hand placed over the 
abdomen can detect inequality on the surface of the contracting organ, 
showing w 7 hat parts are in action and what parts are paralyzed. Under 
the influence of contractions such as these, labor makes little or no 
progress, the bag of membranes does not project in the usual way 
during a pain ; or, if the second stage has been reached, the presenting 
part of the child makes no advance. The woman now becomes ex- 
hausted, the pulse frequent, and the case may assume a grave aspect. 
It is to the more serious forms of this that the name of " uterine teta- 
nus " has been given. 

Inefficient uterine action being thus found to depend upon such a 
variety of causes, it is not to be wondered at that attempts have been 
made to classify the cases. Wigand proposed to divide all into three 
groups. In the first, the womb contracts, not only quite regularly, but 
even to such an extent that the child is bent forwards at each pain, 
and the labor has in general an otherwise normal course ; but this 
course is very tedious, and the pains are interrupted by too long inter- 
vals. This he calls Inertia Uteri. In the second grade, which he de- 
scribes as Adynamia or Atonia Uteri, the uterus also contracts in a 
manner which is, so far, quite regular ; but the contraction is incom- 
plete, of short duration, and inefficient, and lasts longer at the fundus 
than in the lower segment of the organ. In the third grade, all pain 
in the uterus has ceased, so that, beyond a certain feeble tension, no 
trace of contraction is 'to be observed : this condition Wigand describes 
as Lassitudo, Exhaustio, or Paralysis Uteri. Scanzoni proposes that we 
should draw a distinction only between "primary" and "secondary" 
inefficient action, including, under the first term, all cases in which, 
from first to last, the womb lacks sufficient energy to complete the 
labor without assistance; and, under the second, those cases in which 
the contractions were originally sufficient, but have failed in the course 
of labor, so that, in the end, all the symptoms of primary inertia are 
manifested. 

We doubt much whether any such system of classification is of value, 
either as a guide to practice or in elucidating the subject; and we there- 
fore prefer, as embracing all cases of failure of uterine action, the 
simple term Inertia, which is generally used in this sense by English 
writers. Obviously, however, this may exist in any grade, from mere 
feebleness of contraction to absolute paralysis of the uterus. It is 
proper, in considering this subject, not to overlook the possibility of 
failure in the auxiliary expulsive forces; for it must be obvious that, in 
the course of the second stage, anything which may prevent the effi- 
cient action of the expiratory muscles must of necessity interfere, more 
or less, with the act of parturition. Acute or chronic pulmonary dis- 
ease, therefore, as well as cardiac or hepatic disorders, and the ascites 
which often accompanies them, may, with other abnormal conditions, 



XXXVII.] TREATMENT. 599 

so interfere with the dynamical phenomena of parturition as very seri- 
ously to obstruct the progress of labor. 

Treatment. — A careful consideration of the circumstances above men- 
tioned, as applicable to individual instances, will always be our best 
guide to the treatment of those cases in which there is a failure of the 
vis a tergo. An error in the axis of expulsion, which is usually de- 
pendent on anteversion of the gravid uterus, and therefore does not 
strictly fall under our notice here, may be managed without difficulty, 
under ordinary circumstances, by postural treatment or by the abdomi- 
nal bandage, so as to bring the axis of the uterus, as nearly as may be 
possible, into coincidence with that of the pelvic brim. Over-disten- 
sion of the uterine cavity, by reason of dropsy of the amnion, plural 
pregnancy, or any other cause, should, if symptoms of inertia develop 
themselves, be treated by rupture of the membranes, — and that for 
reasons which have already been stated. 

Although, perhaps, rheumatism of the uterus has been somewhat 
exaggerated, as regards its importance as a cause of retarded labor, the 
symptoms should always be taken into consideration, as they are such 
as may divert our attention from the inefficiency of the labor. These 
symptoms have been well described by the younger Naegele. " Rheu- 
matism of the uterus," he says, " is recognized by the following signs. 
During labor, and often before it, the uterus is unusually sensitive to con- 
tact, both from without and from within. The pains are feeble, short, 
infrequent, and unusually painful, and, in fact, excite as much pain at 
their commencement as normal pains do at the height of the contrac- 
tion. During the interval between the contractions, the pain does not 
cease. The woman complains of heat, great thirst, and uneasiness ; 
the pulse is rapid, small, and hard. In the course of labor, the suffer- 
ing from the pains increases, in proportion as their efficiency dimin- 
ishes. In favorable cases, the pains cease for a time, the patient falls 
asleep, after which regular pains soon recur, and continue until the 
completion of the labor; but when the case is mistaken or unskilfully 
treated, the labor becomes extremely protracted, debility and cramp 
come on, and rheumatism passes into metritis." 

In a large proportion of cases, as we have seen, the cause of the 
failure of uterine action is to be found in the condition of the alimen- 
tary canal ; and, on that account, one of the first points that we should 
attend to in all cases, is the condition of the primce vice; and, in like 
manner, and for similar reasons, it is advisable to ascertain the condi- 
tion of the bladder, which sometimes exercises a scarcely less important 
influence on the progress of the case. The effect of relieving a dis- 
tended or irritated viscus is often so striking, that a very common and 
frequently efficient mode of treatment, in cases of uterine inertia, is to 
throw an enema of a stimulating character into the rectum ; and, in 
fact, so susceptible is the uterus, even in these cases, to reflex irritation, 
that a simple enema of warm water will often suffice to awaken its dor- 
mant energy. 

The action of the organ may also be roused by other expedients of a 
still more simple character. A warm diluent drink is often found to 
have an effect as marked as an enema, and when the strength has be- 



600 UTERINE INERTIA. [CHAP. 

come in any way exhausted, it will be proper to substitute for this, 
strong soup, or even some form of stimulant. The accoucheur can 
scarcely, however, be too cautious in sanctioning the use of stimulants 
in labor. Among the lower classes in Scotland, — where whisky is the 
panacea for all evil, — it will often be impossible to prevent its employ- 
ment ; but the universal opinion of all who have witnessed the indis- 
criminate administration of stimulants in labor is that the effect, as a 
rule, is to retard and not to advance the period of delivery. The reflex 
activity of the uterus is often aroused by digital examinations, which 
seem to excite the nerves of the cervex, or those which are distributed, 
in some abundance, to the tissues of the perineum. Free examination 
of those parts, therefore, which, under ordinary circumstances, is to be 
condemned, may here be practiced without hesitation, should the uterus 
show any symptoms of response, a result which will be further en- 
couraged by firm pressure over the surface of the abdomen. 

The position of the woman often exercises, at all stages of labor, a 
very decided effect on the vigor and efficiency of the pains ; and, in a 
woman in whom there is an evident tendency, on the part of the 
uterus, to flag in its efforts, the erect posture, by permitting the child 
to gravitate towards the lower segment, has generally a most beneficial 
effect ; so that it is often proper in these cases to cause the woman to 
walk about the room, even at an advanced stage of labor, in the hope 
that this result may ensue. An abdominal bandage, properly applied, 
will frequently be found to contribute much both to the comfort of the 
woman and the efficiency of the pains, on account of the pressure which 
is thus exercised upon the uterine walls, the stimulus which is afforded 
to the muscular fibres, and the increased efficiency with which the 
abdominal muscles are enabled to act; and in the same manner, no 
inconsiderable assistance may be afforded by firm pressure exercised, 
during a pain, by the palms of the hands placed over the abdomen. 
The effect, indeed, of pressure of this kind is often very striking, so 
much so that of late years general attention has been directed to this 
method of treatment as a substitute for the ordinary oxytoxics. When 
a tendency to inertia exists, something will usually be effected by care- 
fully watching the course of labor, encouraging the woman to husband 
her efforts in the first stage, and urging her to make full use, during 
the second stage, of the expiratory muscles, by closing the glottis, fixing 
the limbs, and abstaining from crying during the presence of pain. 

In a certain number of cases, however, the uterus sinks into a state 
of complete inertia; or the pains become so feeble that it is evident 
that labor cannot be completed by the unaided powers of nature. This 
condition is one which is often attended with no inconsiderable amount 
of risk both to mother and child. If the failure should occur in the 
early stage of labor, before dilatation of the os has been effected, or the 
head has descended into the pelvis, we may place more confidence in 
nature, and may wait for a reasonable time in the expectation that more 
efficient action will be set up; or we may employ the more simple means, 
which have been detailed, with the view of stimulating the uterine 
fibres to contract. When the os is fully dilated, or even, as we have 
seen, at an earlier stage, when we have reason to believe that there is 



XXXVII.] ERGOT. 601 

dropsy of the amnion, rupture of the membranes is a perfectly proper 
and justifiable procedure, and will often be followed, after a brief inter- 
val, by vigorous contraction. Should this fail, or should the inertia 
have become developed in the course of the second stage, we have then 
to choose between the forceps, or some other mode of operative delivery, 
and the oxytoxic agents, of which the ergot of rye is by far the most 
important. 

When the head is low, and the conditions otherwise are such as to 
render the operation both easy and safe, the forceps should, in most 
instances, be preferred ; and, in all cases in which the circumstances are 
such as to call for a speedy delivery, we should have recourse to this 
operation, or to turning. But, when the head is high in the pelvis, 
and there is no obvious necessity for rapid delivery, we may resort to 
some of the agents referred to. 

Ergot, which is, as we have said, the most important of the class of 
drugs to which we refer, is to the accoucheur an agent so important 
and so powerful, that we may here interpolate a brief account of it, 
and of the rules which should guide us in its employment in the exi- 
gencies of ordinary practice. "The Ergot, or Spur," says Christison, 
" seems to affect occasionally all the Graminacese, more rarely the Cy- 
peracese, and sometimes even the Palms. No plant, however, presents 
it so frequently, or of such size, as common rye, — the Secale Cereale. 
It is generally thought to arise under the influence of undue moisture; 
and although this condition seems not to be absolutely essential, it is 
never produced with such certainty as in wet seasons, and in districts 
where the soil is damp, rain frequent, and the atmosphere still and 
misty, especially at the time the grain is coming into flower. In these 
circumstances, it is produced, according to some, by punctures made by 
insects in the glumes, while the substance of the seed is pulpy; others 
conceive that it is caused by the spawn, or sporidia, of a peculiar species 
of fungus." The Ergot of Rye is an irregularly cylindrical body, 
averaging about an inch in length, and slightly curved, like the spur 
of a cock, — hence the name "Spurred Rye." It has a very powerful 
toxic action, and gives rise, when taken in large quantity, or for a con- 
siderable time, to two classes of symptoms, — convulsive and gangrenous. 
It produces, as has been demonstrated by Dr. Brown-Sequard, an in- 
fluence on the vaso-motor nerves, and thus causes contraction of the 
vessels of the spinal cord, on which account it is frequently used in 
congestive and inflammatory affections of that structure. There can 
be no doubt that it is through that channel that its specific action on 
the uterus is produced ; and it unquestionably is the most certain in its 
action of all the agents hitherto discovered in promoting the contraction 
of the muscular fibres. 

Its action may always be counted upon with more certainty when 
the uterus is fully developed ; so that in abortion, it cannot be depended 
upon as likely to promote the expulsion of the ovum, with anything 
approaching to the certainty with which, towards the end of pregnancy, 
the uterus responds to its action. Still, although thus comparatively 
inefficient, there are no circumstances under which its action on the 
uterus may not be manifested ; so that w r e not only find it sometimes 



602 UTERINE INERTIA. [CHAP. 

to act with unexpected vigor in the expulsion of an early embryo, but 
even in the un impregnated organ in the treatment of menorrhagia ; and 
it has occurred to us more than once to be able to demonstrate the 
uterine nature of a doubtful abdominal tumor by the contractions pro- 
duced in it by the action of several doses of ergot. It is, however, 
when labor has actually commenced that the action of ergot is most 
marked; but there can be no doubt that, under other circumstances, it 
operates, although with less certainty, in inducing abortion or prema- 
ture labor, or otherwise initiating uterine action. 

The physiological effects of the drug are, of course, of great interest 
to the accoucheur. We may here pass over, as foreign to our subject, 
its more important toxic effects ; but we may note that it has frequently 
been observed to produce nausea and vomiting, which, of course, may 
absolutely prevent the possibility of its action. In such cases, it has 
been given in the form of enema with perfect success. The usual effect 
on the circulation is a diminution both in the frequency and fulness of 
the pulse, sometimes accompanied with faintness and pallor. In some 
instances, symptoms of cerebral disorder manifest themselves in the 
form of weight and pain in the head, giddiness, delirium, dilatation of 
the pupil, and stupor; but these symptoms commonly follow the uterine 
contractions, and are usually observed in those cases in which an un- 
necessarily large quantity of the drug has been administered. That 
such symptoms may be manifested is enough to show that ergot is 
always to be used with some caution. 

Its action on the uterus, with which we have more particularly to do, 
is generally observed in from ten to fifteen minutes after the medicine 
has been taken, and is indicated by an increase in the violence and 
duration of the pains. When the full effect of the drug has been pro- 
duced, the pains are quite different from those of normal labor, inas- 
much as they are absolutely continuous, or are, at least, without any 
proper interval, although there may be irregular periods of remission. 
Tli is uninterrupted contraction of the uterine tissue necessarily involves 
a certain interference with the utero-placental circulation, over and 
above what occurs in the rhythmical contraction of ordinary labor; and 
it must be admitted that the absence of the natural periods of uterine 
rest may, if long-continued, place the life of the child in peculiar 
jeopardy. This, however, has, we believe, been greatly exaggerated. 
" The ergot," says Dr. Hosack, " has been called, in some of the books, 
from its effects in hastening labor, the pulvis adpartum; as it regards 
the child, it may, with almost equal truth, be denominated the pulvis 
ad mortem: for I believe its operation, when sufficient to expel the 
child, in cases where nature is alone unequal to the task, is to produce 
so violent a contraction of the womb, and consequent convolution and 
compression of the uterine vessels, as very much to impede, if not 
totally to interrupt, the circulation between the mother and child." 
This assertion has been satisfactorily refuted by Chapman, Dewces, 
and others; but still we are inclined to think there is some grain of 
truth in it — at least in those cases in which labor is protracted in spite 
of strong and unceasing pains. Dr. F. H. Ramsbotham supposed that 
the toxic action of the drug might be extended from the mother to the 






XXXVII.] ERGOT. 603 

foetus, and the figures which he gives would seem to go some way to 
prove his assertion. Of 36 cases in which he induced premature labor 
by puncturing the membranes, 21 children were born alive; while in 
26 cases in which labor was induced by ergot alone, 12 children only 
were born alive. Apart from the fact that such statistics are open to 
many fallacies, we repeat our conviction that the danger of ergot to the 
child has been greatly exaggerated ; and we believe that the unsatis- 
factory results which have been reported have been mainly due to the 
rash administration of the drug, without any reference to the conditions 
upon which alone we can rely for a satisfactory result. 

The violence of the contractions produced by ergot is such that we 
are never safe in administering it, unless we are convinced that the 
anatomical conditions are such as to admit of the passage of the child 
without extreme or unusual resistance. To give ergot, therefore, in a 
case of shoulder presentation or of deformed pelvis, when the os is 
undilated, or when the soft parts generally are rigid, dry, and undilat- 
able, is manifestly wrong; and, in the first two cases, would amount 
to malapraxis in the worst form. As regards the condition of the os, 
the rule is as stated, but is not so absolute. If it were so, it would 
debar us from making use of ergot in the induction of premature labor, 
where its action initiates the commencement of the first stage. Nor, 
as regards ordinary cases, are we to admit that we must always wait 
until the os has become dilated ; for there are instances in which a 
dilatable state of the os, with a properly lubricated condition of the 
passages, would be quite sufficient warrant, in the absence of all action, 
for the administration of ergot. If labor should become arrested before 
the os has opened to some extent, there can be no question of medicinal 
treatment, as there is no risk either to mother or child in the arrest of 
a labor which has as yet barely begun. When the head is low in the 
pelvis, the forceps, as already remarked, will usually be preferred ; and, 
if any delay should arise after the exhibition of ergot, the head being 
well in the pelvis, it may be proper to complete the delivery by instru- 
mental aid. Indeed, we believe that the number of cases in which the 
two may with propriety be combined is larger than is generally believed. 
The objection to the forceps, in the case of an absolutely inert uterus, 
is that we may empty the organ, which then, contracting imperfectly, 
admits of alarming or fatal haemorrhage; but if we combine the two, 
the one force will not only aid the other, but the ergot will insure safety 
after delivery by maintaining the womb in a proper state of tonic con- 
traction. If the contractions are violent, speedy delivery is always to 
be desired, as a considerable number of cases of rupture of the uterus 
are on record from the use of ergot alone. 

The mode in which ergot is usually administered is in the form of 
infusion. Two drachms of fresh ergot coarsely crushed may be in- 
fused for twenty minutes in six ounces of boiling water; one-fourth of 
the infusion to be given at intervals often or fifteen minutes until dis- 
tinct uterine action is manifested. If, with the second or third dose, 
the desired effect is already produced, it is wrong to proceed further, 
for the result of more than is necessary will only be to increase the 
tetanic character of the contractions and the risk both to mother and 



604 UTERINE INERTIA. [CHAP. 

child. If the quantity above mentioned has been given in four doses 
without any response on the part of the uterus, it will be needless, and 
indeed improper, to pursue the treatment further ; and cases do, not 
unfrequently, occur, in which the drug seems to be absolutely inert. 
The infusion should always be freshly made ; but the great objection to 
it is that one cannot be sure of the quality of the ergot, more especially 
if it has been kept for any time, when it is apt to become mouldy, or 
to be entirely destroyed by an acarus, which feeds upon it and leaves 
the grain as a mere shell. All these difficulties are got rid of by the 
use of the Liquid Extract or the Tincture of the British Pharmacopoeia, 
either of which may be given in doses of twenty or thirty minims for 
three or four times and at the same intervals as the infusion. Schacht's 
" Liquor Secalis " also contains the active principle of the drug, and 
may be given in drachm doses ; but the liquid extract is the prepara- 
tion which we can with the greatest confidence recommend, as we have 
had more experience in its use. 

Ergot w T as used by women for hurrying labor long before it was 
known to the profession ; and the same remark may be made of Borax, 
which was used by the ancients, and has been employed quite recently 
in Germany by some in preference to ergot, being supposed to be free 
from the objections which attach to ergot as a toxic agent. Cinnamon 
and Strychnia have also been employed, as well as numerous other 
drugs; and a very thorough trial has been made of galvanism, which, 
although it has an undoubted effect upon the uterine fibre, is certainly 
less to be depended on than ergot, and has therefore fallen entirely into 
disuse. 

It has often been stated that the various agents of this class should 
not be made use of in the case of primiparse ; but to the judicious prac- 
titioner such a rule is quite unnecesary, as he will not fail to take into 
consideration the greater resistance which naturally obtains in the case 
of a first labor. There is, in fact, if he does not lose sight of the special 
conditions referred to, no reason why he should not avail himself of the 
action of the oxytoxic agents in priiniparaB as well as in pluriparse. 
For the guidance of the inexperienced practitioner, we will add one 
caution only, — that he should not be too eager in his endeavors to bring 
a case to a speedy termination ; for it often happens that a sudden cessa- 
tion of the uterine efforts is merely an indication that the organ is col- 
lecting itself for more vigorous action and a final effort. 

Precipitate Labor. — Although of less frequent occurrence than failure 
of the expulsive force, the accidents which may accrue in labors which 
are too rapid are scarcely less serious. In the great majority of all such 
cases, there is some peculiarity of constitution or temperament. It has, 
indeed, not unfrequently been observed in the same patient in succes- 
sive pregnancies, and even in different members of the same family. 
It would also appear to be occasionally connected with a morbid irrita- 
bility of the generative system which may have been previously mani- 
fested in undue excitement at the menstrual periods. In some extreme 
instances, the action, from the very commencement of labor, is so severe 
that the patient is compelled to bear down from the first. The appear- 
ance and expression of the countenance, and the state of the pulse, de- 



XXXVII.] PRECIPITATE LABOR. 605 

note a condition of excitement and suffering which is quite abnormal ; 
and, in such instances, we may with some reason dread the occurrence of 
uterine rupture at a stage when we are comparatively powerless to avert 
it. The pains are almost continuous ; and, if the parts are relaxed, the 
child may be forced through the passage with a rapidity which is 
almost appalling. In such instances, indeed, when the woman is taken 
unawares, the child may be born while she is yet in the erect posture, 
and dashed upon the floor. 

Although, as we have seen, the usual effect of premature rupture of 
the membranes is to retard labor, the contact of the uterine walls with 
the surface of the child has occasionally the effect of rousing the organ 
to action of the most violent and uncontrollable kind, although the 
parts may as yet be but imperfectly prepared for the stage of expulsion. 
Emotional causes of various kinds may also have a similar effect in pro- 
ducing contractions, of such energy as to bring the labor to a termina- 
tion with unexpected rapidity. In some cases, the operation of these 
causes is obviously beneficial, and the mere threat of operative inter- 
ference, or the production of the forceps, will sometimes have the effect 
of rousing the flagging energy of the expulsive forces, and bringing 
matters to a termination before operative measures have been resorted 
to. Scarlatina and other acute febrile disorders have in some instances 
a precisely similar effect. 

In another class of cases, the rapidity of the labor seems to be due 
less to the violence of the pains than to the deficiency of the resistance 
to the passage of the child through the parturient canal. In the case 
of a pelvis of unusual size, this may take place, even although the 
pains are in no way beyond the average; and, of course, if such an 
anatomical condition as this is combined with violent uterine action, 
the rapidity of the delivery may be such that only a few minutes in- 
tervene between the preliminary pains and the termination of labor. 
If the head is smaller or more yielding than usual, or the soft parts 
more than ordinarily dilatable, these conditions will also contribute to 
a similar result. 

The dangers attendant upon precipitate labor are various. The ex- 
treme violence of the contraction may cause rupture of the uterus ; or, 
the rapid passage of the child may cause laceration of the cervix, va- 
gina, or perineum, and the more remote dangers to which these acci- 
dents give rise. In other cases, the uncontrollable violence of the ex- 
pulsive action of the voluntary muscles (which in such a case become 
virtually involuntary) may force the air into the cellular tissue, and 
cause emphysema of the face and neck. The sudden emptying of the 
uterus may be followed by a period of complete relaxation, so that all 
such cases are known to be peculiarly liable to post-partum haemor- 
rhage. Rupture of the membranes only makes matters worse, and the 
direct pressure to which, in such cases, the child is subjected, exposes it 
also to no inconsiderable risk. 

Another danger to the child arises from the risk of delivery taking 
place when the woman is in the erect posture, when it may be seriously 
injured by being dashed upon the floor. The rupture of the cord, 
which would probably occur under such circumstances, is not, as some 



606 PRECIPITATE LABOR. • [CHAP. 

have supposed, an important source of danger, seeing that the fact of 
laceration of the vessels, which must take place, is an effectual barrier 
to haemorrhage. It has been observed, in cases in which the resistance 
was much less than the expulsive force, that the uterus, in its undilated 
condition, has been forced down upon the perineum, and has even pro- 
truded externally before the os had sufficiently yielded to permit of the 
passage of the child. 

The treatment of precipitate labor consists in adopting such measures 
as are available for moderating the violence of the uterine action. As 
a considerable number of cases are associated with some intestinal de- 
rangement, it is proper, in the first instance, to wash out the bowels by 
a simple injection of tepid water, the soothing effect of which will 
sometimes become at once apparent. But if, as is more likely, the tur- 
bulence of the uterine action still continues, nothing is so likely to pro- 
duce a decided effect as opium, given in the form of a suppository of 
one of the salts of morphia. This is better than the exhibition of any 
of the preparations of the drug by the mouth, more especially if there 
is a tendency to irritability of the stomach. The other sedatives have 
a similar, although less certain, effect; and, in many cases, the result of 
chloroform inhalation is wonderfully to moderate the uterine action. 

A knowledge of the physiology of the expulsive forces will instinc- 
tively guide us to such management of the case as may obviate, as far 
as possible, any voluntary action. Everything, therefore, which the 
woman might seize, or anything against which she could press her feet, 
should be carefully removed, while the action of the pain should be 
watched, and the woman encouraged to cry out lustily rather than to 
fix the glottis. Such modes of treatment as we have shown to be use- 
ful in inertia, should here be scrupulously avoided, and a directly con- 
trary plan adopted. We should carefully avoid, therefore, digital ex- 
aminations, beyond what may be considered absolutely necessary, and 
protect the patient from all sources of mental emotion or physical ex- 
citement, and from any other cause which experience has proved to ex- 
ercise a decided influence upon the uterine fibre. On no account should 
the woman be allowed to assume or maintain the erect posture, which 
is well known to act as a fresh incentive to uterine action, by allowing 
the child to gravitate downwards and press against the os and cervix. 
Although, theoretically, we might naturally suppose that the ordinary 
abdominal bandage would rather encourage than abate uterine action, 
it has been found that it sometimes has a soothing effect, adding to 
the comfort of the patient, and in some degree relieving her suffering. 
Should this expedient be tried, it will be well so to adjust the bandage 
as to support the womb by pressure applied chiefly between the lum- 
bar and hypogastric regions. When procidentia is threatened, it may 
be necessary to support the uterus by means of a bandage applied ex- 
ternally, and so adjusted as to press against the vulva. When the lower 
segment actually protrudes, a hole should be made in the bandage so 
as to aid the longitudinal fibres of the uterus in mechanically overcom- 
ing the resistance of the circular fibres and tissues of the os. In this 
way Naegele has operated successfully, allowing the child to be born 
actually through the aperture in the supporting bandage. 



XXXVIII.] THE PUERPERAL STATE. 607 

In cases of violent and precipitate labor, the fearful exertion to 
which the patient is impelled may culminate in an epileptic seizure, or 
even in apoplexy. In some cases the suffering is so great and so con- 
tinuous, and the woman is worked up into such a state of frenzied ex- 
citement that, at the moment of delivery, she is actually unconscious of 
what she does. It is in consideration of this that the Continental codes 
look with leniency upon child murder perpetrated under such circum- 
stances ; and, probably, even in our own country, if such facts were 
substantiated, the law would take a similarly lenient view, although it 
is not set forth in the statute-book. Another question in medical juris- 
prudence, and which may have an important bearing in cases of sus- 
pected infanticide, is the likelihood of the mere rapidity of the birth 
being the cause of death of the child, as cases are recorded in which 
children have been born while the woman was in the erect posture, or 
even when she was at stool. It would appear, also, that sometimes, 
owing possibly to the great cerebral excitement, there is a greater 
tendency to the occurrence of puerperal mania, in women in whom 
the symptoms during labor have been of the nature of those above 
described. 



CHAPTEE XXXVIII. 

THE PUERPERAL STATE : LACTATION. 

management oe the puerperal state — the lochia: nature and source of 
— after-pains: treatment of— the lacteal secretion: milk fever: 
colostrum — the child to ee put to the breast at fixed intervals — 
agalactia — galactorrhea : two varieties of — management of lacta- 
tion — effects of over-feeding — duration of lactation — effects of 
menstruation and pregnancy upon lactation — disorders of lactation 
— inflammation and abscess of the mamma: effects of: treatment — 
excoriation and fissure of the nipples : prevention of : treatment of. 

The management of labor, up to the stage when the accoucheur is 
able to leave his patient after her delivery, has already been described 
in a previous chapter. We now propose, however, to consider, some- 
what more in detail, the treatment of the woman during the puerperal 
state, — while she is under the influence of conditions which, although 
strictly physiological, may very readily become morbid. The condi- 
tion of the woman during the period immediately succeeding the ter- 
mination of labor is one of delightful calm and repose, which offers a 
remarkable contrast to the excitement and frenzy of the concluding 
stage of the process. The falling of the pulse shows the subsidence of 
a turbulent circulation, and is due, in some degree, to a modified shock. 
When labor has been easy, and of moderate duration, there are no 



608 THE PUERPERAL STATE. [CHAP. 

symptoms of shock ; but in other cases, and in proportion to the vio- 
lence and duration of the process, the patient shows symptoms, more 
or less distinct, of debility, and the shock to the nervous system mani- 
fests itself further by intolerance of light and sound and other symp- 
toms of temporary exhaustion. Perfect quiet, and, above all things, 
refreshing sleep, will speedily rouse the woman from the condition into 
which she has fallen ; and so important, indeed, is the latter point, that 
many experienced practitioners were in the habit of giving an opiate, 
as a matter of routine, shortly after delivery. In ordinary cases, how- 
ever, opium is unnecessary ; but, whenever there is shock and marked 
exhaustion, a moderate dose of the Liq. Opii Sedativus may frequently 
be given with advantage. 

The old method of treatment by starvation during the first few days, 
— when the diet was confined to tea, water-gruel, or arrowroot — finds 
few, if any, supporters at the present time. Nothing, indeed, could be 
more irrational than such treatment, or more likely to retard recovery 
and discourage the lacteal secretion ; so that it will be quite proper, 
after the first day at least, in the great majority of instances in which 
the patient has had some sleep, to give chicken-soup, or beef tea, in 
addition to the dry toast, gruel, arrowroot, and sago, which are properly 
given at this stage, as being substances easy of digestion. 

In the course of his subsequent visits, the accoucheur should see that 
the bandage is properly managed, and tightened from day to day; and 
it is well, by firm and equable pressure, exercised over the hypogastric 
region — which has often the effect of dislodging clots — to be assured 
of the satisfactory state of the uterus as regards contraction. One of 
the first points to which he addresses his inquiries is with reference to 
the function of the bladder, which is sometimes resumed with difficulty. 
Laving with warm water w T ill usually be all that is required to excite 
the bladder to contraction ; but, in some cases in which the labor has 
been difficult, the viscus is actually paralyzed, so as to require the use 
of the catheter, which may have to be repeated for several days. 

If the bowels have been freely moved, as they should always be, 
shortly before delivery, we need pay no attention whatever to that 
function until forty-eight hours have elapsed. Torpor of the bowels is, 
after labor, an almost invariable condition, which is probably due, as 
Dr. Tyler Smith says, to " the exhaustion induced by labor in all the 
organs under the influence of the spinal cord. 7 ' Under the ordinary 
conditions of the puerperal state, it is, therefore, necessary to give some 
laxative medicine — of which class of remedies castor oil is undoubtedly 
the best. Other laxatives may, no doubt, act with equal efficiency ; 
but, as a rule, and especially in the form of pill, they are not to be 
depended upon. It is somewhat remarkable that, sluggish as the 
bowels are, they respond very readily to the action of laxatives, even 
in the case of those who are habitually costive. It will therefore rarely 
be found necessary to prescribe more than a dessertspoonful of castor 
oil, which may be given with lemon-juice early in the morning. On 
several occasions we have seen an ordinary dose of half an ounce 
followed by such violent action as to require opiates to restrain the 
purging. 






XXXVIII.] TREATMENT AFTER DELIVERY. 609 

[The teaching of the author in regard to the use of purgatives is in 
accordance with that of most systematic writers on obstetrics. Pro- 
fessor Fordyce Barker, of New York, however, in his work on Puer- 
peral Diseases, strongly condemns the administration of castor oil to 
lying-in women, especially such as are predisposed to haemorrhoids. 
When the editor began the practice of medicine, it was the rule to give 
a dose of oil on the third day after confinement. Any departure from 
this time-honored custom was the subject of severe criticism, upon the 
part of both the patient and her nurse. The action of the castor oil 
was frequently attended with violent straining and hypercatharsis, 
which sometimes resulted in an attack of the piles, which the woman 
bore with a martyr-like resignation, because she was led to believe that 
it would ward off some indefinite trouble, which it was feared would 
follow if the medicine was not taken. 

These facts led the writer to abandon the use of castor oil among his 
puerperal patients, and instead of looking upon it as " the best" laxa- 
tive medicine that can be employed under these circumstances, he 
believes it to be one of the worst, on account of the uncertainty of its 
action. 

In many cases there is no necessity to administer a purgative on the 
third day, and we can fully confirm Professor Barker's statement, that 
many women need no laxative at all, as the bowels often act spon- 
taneously between the second and fourth day after delivery. If they 
do not they can be stimulated by an enema, a small dose of rhubarb, 
or two or more of Lady Webster's dinner pills. — P.] 

The Lochia. — While the placenta, during the third stage of labor, is 
being separated and expelled, a considerable amount of haemorrhage 
naturally takes place, and, after the completion of the process, blood 
continues to ooze from the ruptured and partially closed vessels on the 
inner surface of the womb. Efficient and rhythmical contraction of 
the uterus prevents the flow from becoming so profuse as to be dan- 
gerous ; but still, a certain amount of discharge goes on for a time; 
and, indeed, it is well known that the maintenance of this discharge, 
for a certain time after delivery, is, to some extent, a guarantee of the 
favorable progress of the case, while, on the other hand, its premature 
arrestment is an almost invariable accompaniment of the more serious 
puerperal disorders, and is therefore always looked upon with more or 
less of apprehension. In order to understand the true nature of the 
lochial discharge, it is necessary to consider for a moment the anatomical 
condition of the parts from whence it springs. 

That part of the uterus from which the placenta has been separated 
was compared by Harvey to the stump of a limb after amputation ; 
but, although the simile has been frequently repeated, physiologists are 
well aware that it is only to a limited extent correct. The vessels, no 
doubt, are torn across in the course of the separation of the placenta, 
but, with this exception, there is no real breach of tissue, as nature has 
for many weeks been preparing for the process of separation. At birth, 
the inter-utero-placental tissue divides into two layers, as was formerly 
explained, one of these remaining adherent to the uterine wall, along 
with portions of the decidua serotina. If the womb be examined 



610 THE PUERPERAL STATE. [CHAP. 

shortly after delivery, that part of it to which the placenta was attached 
will be observed to be thicker than the other portions, and projecting 
somewhat into the cavity of the uterus. Upon this surface, which is 
rugged and unequal, small clots, projecting from the orifices of the 
closed vessels, and so contributing to their efficient closure, are ob- 
served, along with shreds of membrane; and, over the whole inner 
surface of the cavity of the organ, remains of the decidua vera or of 
the subjacent textures from which it has been stripped are clearly to be 
made out. The discharge, then, which constitutes the lochia is, in the 
first instance, composed of almost pure blood. After this, it is still 
sanguineous, but has been found by M. Robin to contain an unusually 
large proportion of white corpuscles. As the discharge changes in char- 
acter, the proportion of white corpuscles becomes higher and higher, 
and these are believed by the same authority to have their origin 
directly in the inner surface of the uterus. After the second day, the 
white corpuscles increase in number, while the red globules diminish. 
The discharge gradually assumes a reddish-gray, and then a greenish 
or yellowish hue, at which period there are scarcely any red corpuscles 
to be found. The white corpuscles are, however, the predominating 
element, and some of them may now be observed to have become 
voluminous and full of fatty granules, having in fact assumed the char- 
acters which have gained for them the name of "granular globules. " 
Along with these elements will be found fragmentary traces of the 
decidua, and also pavement epithelium from the mucous membrane 
of the vagina. 

The lochial discharge has a peculiar odor, sometimes offensive in 
character, but at no time, if it follows a normal course, is there a puru- 
lent discharge, nor is the process in any way analogous to the suppura- 
tion which accompanies the reparative process of a healing stump. 
While the remains of the decidua are thus being separated, the small 
clots which plug the vessels, or are adherent to the surface, undergo a 
process of disintegration, and are separated along with the other con- 
stituents of the lochia. The new mucous membrane, which, according 
to Robin, begins to form beneath the decidua as early as the fourth 
month, is distinct about the ninth day, when the columnar epithelial 
cells begin to be developed. The surface then becomes smooth, and 
the discharge becomes colorless and finallv ceases, these changes going 
on pari passu with the process of fatty degeneration of the muscular 
fibres which has been previously described. 

Care should be taken by the nurse to promote, while avoiding un- 
necessary interference, the lochial discharge. A strict regard to clean- 
liness is the most important indication. The external parts are, with 
this view, to be sponged lightly with tepid water, and the napkins 
changed as often as may be necessary ; and, if the foe tor is unusually 
great, or if the- part have been lacerated, it is well to wash out the 
vagina daily by a warm water injection containing a small quantity of 
carbolic acid. The discharge is also promoted by the acts of defecation 
and micturition, and by any change of posture; and it is a good prac- 
tice, after the second day, if nothing should occur to contraindicate 
such a procedure, to encourage the woman to make water on her knees, 



XXXVIII.] THE LOCHIA. 611 

which permits of the escape of any portion of the fluid which may have 
become accumulated in the cavity of the vagina. 

After-Bains are the natural accompaniments of the contractions which 
usually take place after labor, having for their object the expulsion of 
any clots that may be contained within the cavity of the uterus, and 
probably the expulsion of the clots which seal the vascular orifices. 
These after-pains are trifling or altogether absent in primiparse, but are 
almost always present, in a greater or less degree, in women who have 
previously borne children. Up to a certain point, they have a decidedly 
salutary effect, and contribute to the favorable progress of the case; 
but it not unfrequently happens, particularly in women who have had 
many children, that they are so severe as to cause much suffering and 
no little constitutional disturbance. Anything, in these cases, which 
tends to engender reflex uterine contraction will be pretty sure to ag- 
gravate the symptoms, so that vaginal examinations and irritation of 
the rectum and bladder should, as far as possible, be avoided or recti- 
fied. One of the most familiar causes of after-pains, so common as to 
have given rise to an aphorism among nurses, is the application of the 
child to the breast; and the accoucheur should generally avail himself 
of this well-known fact to insure thorough and efficient uterine con- 
traction. And we may here repeat what was stated on a previous 
occasion, that nothing, perhaps, tends so much to insure that the after- 
pains shall be moderate in degree, as firm pressure on the fundus, and 
careful attention to the contraction of the uterus during and after the 
expulsion of the placenta. 

The after-pains usually commence soon after labor, and in bad cases 
they last for three or four days. In other cases, again, they are at first 
moderate, and, after some time, come on with great violence. If there 
be any suspicion of retained coagula, it will be proper to pass the finger 
into the vagina, and remove any clots which may be within reach. 
Should no such cause be discernible, and the pains still persist, the 
application of a warm poultice over the hypogaster, or a soothing injec- 
tion into the vagina, will often suffice to allay the suffering, if not to 
cause perfect relief. In France, an ointment containing belladonna 
has been extensively used, and no doubt may be productive of benefit, 
but the objections to the general use of this drug have already been 
stated. In some instances, the pains are distinctly neuralgic, or are 
associated with a rheumatic condition of the uterus ; and in these, as 
well as in all other cases in which the sufferings of the woman go beyond 
a certain point, and especially when they prevent sleep, opium may be 
given without hesitation, either by the mouth or by enema. It is well, 
however, before giving opium in any form, to be sure that there is no 
irritation of the bowel, from overdistension or any other cause, as it 
will be proper to relieve that condition before having recourse to seda- 
tives. Dr. Tyler Smith found benefit occasionally to result from the 
application of an anodyne embrocation to the breasts. It must be 
clearly understood that after-pains, although due, in their usual form, 
to a physiological action, are, when severe, not to be neglected; for,, 
not only may the want of sleep and constitutional irritation lead to> 
unpleasant results, but the case, if abandoned to nature, may even pass 



612 THE LACTEAL SECRETION. [CHAP. 

into inflammatory disease, which, at this particular epoch, is, as we 
shall see, peculiarly disastrous in its effects. 

[Professor Barker [Puerperal Diseases, p. 8) describes a variety of 
neuralgic after-pains which is met with occasionally. In these cases 
the abdomen is neither tender nor distended, but the uterus, though 
normal in size, is tender on pressure. There is no febrile reaction. 
This condition does not yield to opiates, but is promptly relieved by five 
to ten grains of quinia, given night and morning. At the same time, 
Dr. Barker recommends that a liniment, composed of chloroform §j 
and compound soap linament §vj, should be applied to the abdomen on 
flannel.— P.] 

The Lacteal Secretion. — The enlargement of the breasts, which is so 
characteristic a sign of pregnancy, is usually accompanied, not only 
with increased development of the mammary glands, but also, during 
the last few months of gestation, with a secretion of more or less milk. 
The quantity is, however, small, and although it may, in some cases, 
be pressed out in jets from the nipple, there is no accumulation of the 
fluid in the ampulla? of the galactoferous ducts. In most women, no 
marked alteration takes place until about the third day, when the secre- 
tion of the milk — properly so-called — commences. At this time, there 
often is what has been described as a rush of milk to the breasts. The 
glands become considerably enlarged and greatly more vascular, and 
the pulse very commonly rises a little, when the mother may complain 
of headache. A febrile condition has indeed been described by the 
older writers as a normal accompaniment of the establishment of the 
secretion, but the constitutional symptoms to which the local determi- 
nation of blood at this time gives rise can scarcely with propriety be 
described as a fever. This is true, at least, in regard to all ordinary 
cases ; but it is by no means an unusual occurrence for the patient to 
be attacked with a rigor, which is generally slight, followed by heat of 
skin, rapid pulse and headache — symptoms which are relieved by free 
perspiration and a copious secretion of milk. 

This is what is commonly known as Milk Fever, and is identical 
with what is otherwise described as ephemera or weid. Whatever the 
degree of fever may be, the state of the breasts requires prompt atten- 
tion. One of the advantages of putting the child early to the breast is 
that it draws out the nipple, which may be small or flat ; and what is 
now very likely to occur, should this have been omitted, is a projection 
of the areola, which participates in the tumefaction of the rest of the 
gland, so that the nipple falls in as it were on a level with the skin, 
when it becomes a matter of some difficulty for the child to seize it. 
Putting the child to the breast is the natural and almost instinctive 
method which the woman adopts for the relief of the painful distension 
which she experiences, but as the child at first drinks but sparingly, it 
may be necessary for the nurse to relieve the gland by the use of the 
breast-pump or otherwise, aided by gentle frictions with olive or cam- 
phorated oil. These may be directed more especially to such portions 
of the gland as may show a tendency to induration or knotting, due in 
the first instance to local accumulations of milk, and subsequently, if 
neglected, to inflammation of the surrounding tissues, which may pro- 



XXXVIII.] LACTATION. 613 

eeed to abscess. It is always of importance to keep the breasts cool at 
this stage, and it may even be necessary to keep down the temperature 
by evaporating lotions when there is reason to apprehend the more 
violent action which is apt to culminate in abscess. No small amount 
of suffering arises in some instances from the weight of the inflamed 
gland,, which gives rise to dragging and aggravation of all the symp- 
toms. This condition can fortunately be greatly relieved by the simple 
expedient of suspending the breast by means of a handkerchief slung 
round the neck. 

It is a very usual thing for nurses to put the child frequently to the 
breast, with the view of relieving such symptoms as are here described. 
This, however, should always be done with caution, and in view of the 
whole circumstances of the case. For, it must be remembered that this 
effect of the contact of the child is not only to empty the breasts but 
also to stimulate them to increased secretion, and if this latter effect — 
as it well may be — is in excess of the former, the treatment is obviously 
injudicious, and is likely either to precipitate the direct effects of in- 
flammation, or to induce an excessive secretion of milk, which in most 
women has a serious effect upon the general health. Besides, the too 
frequent contact of the child is apt to cause certain painful affections of 
the nipple, to which we shall afterwards advert, and is by no means 
free from risk to the child itself. 

The Colostrum, or milk first secreted, is somewhat irritant, and thus 
has a satisfactory effect in removing, by its laxative action, what re- 
mains of meconium in the bowels, and in preparing the mucous mem- 
brane of the alimentary canal for its functions of assimilation and excre- 
tion ; but the too frequent ingestion of this, or even of perfectly 
developed milk, is apt to keep up a continuous digestive action in the 
stomach, and give that viscus no time to rest; and even when the child 
sucks vigorously, the repeated overdistension of the stomach only 
results in rejection again and again of what has been swallowed. The 
mother ought, if possible, on each occasion, to put the child to both 
breasts, as the emptying of one, and leaving the other in a state of com- 
plete distension, as is sometimes done, is not likely to contribute much 
to her comfort. It % is always better partly to empty both breasts than 
wholly to empty one. 

It is, therefore, of great importance that the mother should be warned 
from the first not to put the child too frequently to the breast. If 
the child sleeps by her side, this is the ready method of cure for rest- 
lessness and screaming fits, and the child is often allowed to fall asleep 
with the nipple in its mouth; but, if it once contracts this habit, it may 
become impossible for it to be put to sleep in any other position, while 
it drinks at intervals without the consciousness of the mother. This, of 
course, an experienced nurse will never permit, but it is a matter of 
greater difficulty to determine what is sufficient nourishment for an in- 
fant, and at what intervals it should be given. This would perhaps fall 
more properly to be considered in the following chapter, but as it in- 
volves the interests of the mother as well as those of the child, we may 
here observe that it is of much importance to accustom the child from the 
first to drink at regular intervals. These, to begin with, may be every two 



614 LACTATION. [CHAP. 

hours, or if the child be premature or feeble, and on that account able 
only to take a small quantity of nourishment at a time, it will be 
necessary to put it to the breast at shorter intervals. But the object of 
the mother should always be to increase the interval until, after the 
second or third week, the infant becomes accustomed to take its natural 
nourishment every three or even four hours. This enables the mother 
to have her natural rest, and allows of the steady and satisfactory filling 
of the breasts against the stated periods. 

It often happens, in women, too, who have an abundant supply of 
milk, that much disappointment results from the frequent escape, and 
consequent waste of the secretion. A certain amount of overflow, just 
at the commencement, when the breasts are tumid and distended, is so 
far beneficial ; but when this goes on, — independent, it may be, of the 
amount of the secretion — it comes to be a serious matter, and may give 
rise to no little perplexity and annoyance. The milk which thus runs 
from the breasts may keep the woman in a constant state of moisture 
and discomfort, and although it is possible to collect the fluid dis- 
charged in small vessels which are used for the purpose, and even to 
give it to the child by a spoon, this is always an unfortunate occur- 
rence. It is certain that, by careful attention to the period at which 
the child should be put to the breast, on the one hand guarding against 
overdistension, and on the other avoiding frequent and irregular ap- 
plications of the child, much may be done to prevent this loss. In 
some cases, when the glands reach a certain stage of distension, the 
woman is conscious of a feeling of momentary discomfort, and then of 
involuntary contraction, immediately after which the greater part of 
the accumulated secretion is expelled, not unfrequently in jets. In 
other instances, this spasmodic contraction is excited by the contact of 
the child, when both breasts are simultaneously the seat of contraction, 
so that while the infant is half choked with the milk of one breast, 
that of the other is expelled in jets as before. In another class of cases, 
the application of the child is attended with acute pain in the breast 
of a neuralgic character, sometimes, indeed, so severe as to cause the 
woman to cease nursing. Emollient and sedative applications, such as 
belladonna, have been employed with the view of soothing this painful 
affection; but in some cases it defies both these and internal remedies, 
and ultimately compels the woman to yield. 

Every conceivable shade of difference is found to exist between dif- 
ferent women, even of the same constitution and temperament, in the 
quantity of the lacteal secretion, and also in regard to its quality. In 
one case, we find a delicate, fragile woman, who may even be the sub- 
ject of constitutional disease, and who is, nevertheless, overburdened 
with milk ; while, in the next which comes under our notice, a young, 
robust, and vigorous woman, who has never had an hour's illness, fails 
completely in so far as the lacteal function is concerned. We do not, 
of course, mean to imply that these are common cases, but they are 
certainly not such as would cause the experienced practitioner a mo- 
ment's astonishment. The commencement of lactation may, in like 
manner, be ushered in with all the usual symptoms, and be at first 
abundant only to fail in a few days ; while, in another, the secretion is 



XXXVIII.] GALACTORRHEA. 615 

ultimately satisfactorily established after a period of doubt and diffi- 
culty. Although, therefore, we know that strong and healthy women 
are more likely to prove good nurses, we can never be certain, until a 
week, or even longer, has passed, how the case, in this respect, is likely 
to turn out. There is no doubt that, although there are other condi- 
tions which influence the secretion of the milk, the state of the uterus, 
and the natural sequence of events of which it is the seat, exercise an 
important influence, owing to the well-known sympathy which sub- 
sists between the organs. 

In the condition which has been termed Agalactia, the secretion is 
either altogether arrested, or is manifestly insufficient in quantity for 
the nourishment of the infant. Among the most frequent causes which 
lead to this condition are acute diseases, more especially if they imme- 
diately succeed the period of delivery. It is, in fact, one of the most 
common symptoms of those febrile diseases which sometimes supervene 
on the puerperal state, to the alarm of the attendants, and not seldom 
with the most disastrous results ; and the failure of the secretion is 
always looked upon as of more serious import, if it is accompanied by 
the premature cessation of the lochia. But, independent of any other 
marked or serious symptom, there is sometimes a simple failure of the 
discharge, where it is difficult or impossible to recognize the cause. 

We are not, however, to suppose that such failure is conclusive evi- 
dence of permanent incapacity, on the part of the woman, to discharge 
this natural function. If due to a febrile condition of moderate dura- 
tion, the discharge will often reappear with the abatement of the pyrex- 
ial symptoms ; so that, by feeding the infant artificially for a time, we 
may wait until we see whether or not the function will be re-established. 
This will be furthered by the application of warm fomentations to the 
breasts, and of late years the leaves of the castor-oil plant have been 
extensively used as a local application, with the view of increasing or 
exciting the secretion. For this purpose the leaves are to be boiled in 
a small quantity of water, and are to be applied along with the water 
in which they have been infused, in the form of a fomentation. 

The quantity of the lacteal secretion is, under no circumstances, to 
be accepted as a criterion of its quality. The eye enables us, in some 
measure, to judge of the abundance of the corpuscular elements upon 
w T hich the nutritive value of the secretion mainly depends. This may, 
however, be more accurately ascertained by means of a lactometer, or 
by the use of the microscope ; but it is to be remembered that the 
richest milk is by no means that which is necessarily best suited for the 
child. 

Galactorrhea , or a too abundant secretion of milk, has been described 
under two forms, involving very different conditions and management. 
In the one, the quantity alone is abnormal, the nutritive value of the 
secretion being unaffected, so that our object in treatment would natu- 
rally be to guard against such an unnecessary drain upon the mother, 
as might be expected ultimately to compromise her general health. 
In this variety, the effect produced upon the child may be perfectly 
satisfactory, the only inconvenience, in many cases, being from the 
rapidity and abundance of the flow from the reservoirs within the gland, 



616 LACTATION. [CHAP. 

so that the mouth of the child fills much more rapidly than it can 
swallow, to its great and obvious discomfort. The treatment of such 
a case should consist mainly, if not entirely, in regulation of the diet, 
watching narrowly the while what effect is being produced upon the 
health of the mother, and adopting such means as may seem necessary 
for its rectification, by the partial arrestment of the discharge, or other- 
wise. 

In the other variety of galactorrhea, the conditions are widely dif- 
ferent. Here, too, there is abnormal abundance ; but, in addition, we ' 
find that the increase in bulk depends mainly or entirely upon an 
augmentation of the watery part of the fluid. Not only is this a state 
of matters extremely unfavorable to the infant, but it is often observed 
to exercise an unsatisfactory influence upon the mother. Indeed, in 
extreme cases, so serious and so obvious are the effects thus produced, 
that the expression " Mammary Diabetes" has been suggested by the 
rapid emaciation which occasionally supervenes. Along with great 
feebleness, there unfortunately exists sometimes, in these cases, com- 
plete loss of appetite, so that it is almost impossible to combat the 
symptoms by what we might judge to be appropriate diet. When the 
anorexia is less marked, the digestive functions may be disturbed, — 
gastric and intestinal disorders being of frequent occurrence, taking the 
form, it may be, either of vomiting with heartburn and pyrosis, or of 
obstinate diarrhoea with flatulent distension and tenesmus. In those 
cases, ordinary remedies may prove of little avail, and after a few weeks 
of struggle it will become evident that no alternative remains except 
to wean the child, and take such other measures as may permanently 
arrest the secretion. This affection is believed to be particularly dan- 
gerous to those who have any phthisical tendency. 

From what has been said, it will be sufficiently obvious that the 
Management of Lactation must not unfrequently be a prominent part 
of the duties of the accoucheur. Nothing, in this respect, is more 
important than that the diet of a nursing woman should be, in quantity 
and quality, such as is most likely to conduce to the health of the 
child, as well as to her own. In the case of a perfectly healthy woman, 
but little attention to regimen is required, — nothing further being 
necessary, in such instances, than that the woman should avoid any 
imprudence in diet, while in other respects she need make no change 
in her ordinary habits. The pregnant state, however, and the subse- 
quent exhaustion which attends the process of parturition, very generally 
leave the woman in a condition which manifestly requires generous 
treatment, in order that the health may be re-established, while pro- 
vision is made for the special drain on the system which the function 
of lactation involves. Among the higher classes, where luxurious 
habits tend to the diminution of constitutional vigor, and among the 
inhabitants of towns, the necessity for such treatment is much more 
prominently marked than in country districts, where a life of physical 
exertion, spent, to a great extent, in the open air, implies hygienic con- 
ditions which are the very opposite of those which we observe in the 
other case. In ordinary practice, however, the necessity for a liberal 
dietary is so universally recognized that there is a danger of falling 



XXXVIII.] MANAGEMENT OF LACTATION. 617 

into a routine practice in this respect, the result of which will, un- 
doubtedly, in some cases, be the reverse of beneficial. 

As the result of some experience and close observation, we are con- 
vinced that indiscriminate overfeeding and stimulation of nursing 
women is a more frequent cause of the disorders of early infancy than 
is usually supposed. Nurses and mothers can readily understand how 
a thin and watery milk should fail to nourish the child, but it is by no 
means so easy to convince them that a specimen rich in nutritious ele- 
ments may possibly be, from its very richness, the cause why an infant 
does not thrive. We have again and again seen cases of obstinate 
diarrhoea, with or without vomiting and other symptoms of gastro- 
intestinal derangement, which could only be attributed to this cause. 
Drugs are of no avail : the appearance of the mother may be such as to 
prevent even a suspicion of any fault on her side, and yet strict inquiry 
as to what she eats and drinks often points clearly to the simple and 
only proper treatment. It is to the use of stimulants that the attention 
should in these cases be more particularly directed ; for we often find 
that women are encouraged, without any reference whatever to their 
general health, or the state of the milk, to take considerable quantities 
of ale or stout, or of the stronger wines. Diminishing the quantity of 
these stimulants, and in some cases absolutely forbidding their use, will 
certainly, in many instances, be followed by a marked and immediate 
amelioration in the symptoms. But, even when stimulants are not ad- 
mitted into the dietary, the cause may still be discovered in the habitual 
use of food which is too stimulating in its character, or which is taken 
in too great quantity. 

An interesting series of observations, bearing directly on this sub- 
ject, have been deduced from analyses conducted by M. Peligot, with 
the view of ascertaining the nutritive value of the lacteal secretion at 
various epochs. From these analyses it would appear that the longer 
the milk remains in the breast, the thinner and more aqueous does it 
become. It has been clearly established, further, that the milk which 
first flows from a distended breast — this being the portion soonest se- 
creted — is comparatively watery, and that the quality of the milk be- 
comes richer as the gland is progressively emptied. Hence a very 
obvious indication of treatment. When, for example, the child seems 
to be suffering from too rich milk, and there is reason to suppose that 
it is put too frequently to the breast, before the gland has time to fill, it 
may suffice to extend the period between the repasts, which, by giving 
the gland time to fill, also insures that the child obtains a less rich 
milk, and one more suited to its digestive capabilities. And we be- 
lieve that the same facts may possibly be turned to account in the treat- 
ment of the opposite class of cases, where the secretion is too watery, 
and yet abundant, by partially emptying the breast before the child is 
put to it, so that, the more watery portion of the milk being removed, 
the child obtains the more nutritious residue. 

The duration of lactation varies very considerably. It may cease 
quite unexpectedly, a few weeks, or even days, after the secretion has 
been established, or it may last for years. Between these two extremes 
the range is obviously great ; but, as a rule, in cases in which the 



618 LACTATION. [CHAP. 

whole circumstances are perfectly normal, the average duration may 
be set down as from twelve to fifteen months. This is, of course, sup- 
posing that the woman goes on nursing, and that nothing is done with 
the view of interrupting the function. The influence which is pro- 
duced upon lactation by the menstrual function, is a subject in regard 
to which very vague ideas are sometimes entertained. As a rule, a 
woman does not menstruate while she continues to nurse, so that no 
disturbing influence from this source normally exists. In a very con- 
siderable number of instances, however, she menstruates after five or 
six months ; and, in a small proportion of cases, the menstrual function 
is regularly discharged during the whole period that she gives suck. 
Much discussion has taken place as to the influence which the consti- 
tutional disturbance inseparable from the menstrual molimen exercises 
on the process of lactation ; and the question is often put to the medi- 
cal attendant, whether the appearance of the catamenia is a sufficient 
reason for ceasing to nurse. It is beyond doubt that, in a large num- 
ber (probably the majority) of cases in which menstruation occurs dur- 
ing lactation, no perceptible effect is produced upon the child. It is 
equally true, however, that marked disturbance of the one function 
attends the premature establishment of the other, as is evidenced by 
the most delicate of all tests, — disturbance of the functions of the child, 
which in some cases is very marked, and recurs at successive menstrual 
epochs. We must not, therefore, in replying to the question stated 
above, rashly assume, either that menstruation forbids nursing, or that 
it is to be disregarded. The truth lies between the two, and the solu- 
tion of the question is to be found in a careful observation of the effects 
which are produced on the mother and child, upon which alone a defi- 
nite opinion can be formed. 

It sometimes happens that a woman becomes pregnant while she is 
still nursing, although the rule is that, during lactation, the generative 
functions are in abeyance, in so for, at least, as ovulation is concerned. 
In the exceptional instances referred to, it is not too much to suppose 
that, the whole generative force being diverted into a new channel, the 
nursing power must necessarily diminish ; and that this is actually the 
case, is the experience of all who have watched these phenomena most 
closely. During the first weeks of such a pregnancy, the lactation 
may be but little disturbed, although there is good reason to believe 
that a failure in the amount of the milk, or an alteration in its quality, 
precedes, not unfrequently, the period at which the woman becomes 
conscious of her state. On the whole, we do not hesitate to assert that 
the existence of pregnancy is a clear indication that the woman should 
cease to nurse. 

The important function of lactation is liable to certain disorders, or 
disturbing influences, the management of which comes necessarily un- 
der the duties of the medical attendant. The most familiar of these is, 
undoubtedly, Inflammation of the Mamma ; and, when we consider 
the sudden determination of blood, and consequent turgescence of the 
gland, our feeling may be one of astonishment, not that it often in- 
flames, but rather that it, as a rule, escapes inflammation. From 
whatever cause it may spring, the condition of the gland during the 



XXXVIII.] MAMMARY ABSCESS. 619 

puerperal state must manifestly be such as to favor the extension of 
inflammatory action which has arisen within the structure. Exposure 
to cold, the irritation of sore nipples, and constitutional disturbance of 
various kinds, are a few, among; many, causes leading to local inflam- 
mation, which almost invariably attacks, in the first instance, the 
tubular structure of the gland. But a mere local affection of an exter- 
nal organ of limited extent, would probably be looked upon with little 
alarm, were it not for the fact that there here exists a peculiar liability 
to the formation of pus, resulting only too frequently in the formation 
of Mammary Abscess. 

It is said that women of a weakly, delicate, or scrofulous constitution 
are peculiarly liable to mammary abscess ; but, whether this be the case 
or not, there are many cases in which, in women of perfect health and 
vigorous constitution, this troublesome affection quite unexpectedly 
manifests itself. There is, certainly, a great tendency to its reappear- 
ance in those who have suffered on a former occasion ; but, beyond this, 
there is no marked predisposition upon which we can rely. The in- 
flammation which precedes the formation of abscess is, if it be at all 
severe, ushered in by rigors, which are often of considerable severity. 
This is immediately followed by fever, and very shortly by lancinating 
pain in the breast, which is increased on pressure. The site of the pain, 
usually circumscribed, is further indicated by the presence of swelling 
and hardness, which, in favorable cases, become gradually resolved as 
the inflammation subsides, without the formation of pus. 

But, when abscess forms, the progress of the case is widely different. 
The inflammatory action, commencing, as we have seen, in the glan- 
dular structure, extends to the cellular tissue. The tumor, hard before, 
becomes less circumscribed and softer, although no less painful. The 
general symptoms are unabated; and, as the swelling still further 
increases, the cutaneous surface becomes hot and red, and ultimately 
cedematous, and glazed or shining. The latter symptoms indicate the 
formation of pus, the presence of which is still more clearly manifested 
by the feeling of fluctuation, which becomes more and more distinct as 
the cavity enlarges, and the pus approaches the surface. With the 
formation of matter, there may be a renewal of the rigors, and there is 
generally painful throbbing and exacerbation of the fever. Finally, 
the cutaneous tissues yield, and the abscess bursts, discharging its con- 
tents, to the great relief of the patient. Unfortunately, however, her 
troubles do not always cease here; for, under the influence of a pro- 
tracted drain on the system, she may be reduced to a condition of 
deplorable weakness, which may be aggravated by obstinate gastric or 
intestinal derangement, or by profuse night-sweats. The cases which 
are, in the first instance, the most severe are not necessarily those which 
ultimately produce the most serious effect upon the patient. It is true 
that the symptoms are, at first, in proportion to the violence of the 
inflammation and the extent of the abscess. But, on the other hand, 
the violence of the attack is often, under such circumstances, apparently 
expended ; and, unless the discharge is abnormally protracted, the 
gland may gradually resume its healthy condition and normal function, 
w T hile the constitutional symptoms rapidly disappear. 



620 LACTATION. [CHAP. 

In another class of cases, the symptoms at the outset are compara- 
tively moderate, and the abscess correspondingly small. When the 
latter discharges itself, or is relieved by operation, the cavity contracts, 
and we imagine that the case is at an end. But, ere long, the former 
symptoms reappear, a second abscess forms, runs its course, and dis- 
charges its contents as before ; and, in some cases, a succession of such 
local inflammations, individually of limited extent, may produce, col- 
lectively, such effects as more seriously to influence the health than a 
case which may at first have excited more apprehension in our minds. 
In those cases of repeated small abscesses, there is often extensive in- 
duration, which may affect the whole, or the greater part of the gland, 
especially that part of it immediately surrounding the nipple. 

[For purposes of study, inflammation of the mammary gland may be 
divided into three varieties ; that affecting the areolar tissue of the 
organ ; that involving the tissues between the breast and the chest- wall 
(subglandular inflammation) ; and lastly, that affecting the glandular 
tissue proper. The first and second varieties do not differ in their 
nature from simple phlegmonous inflammations in other parts of the 
body, but the subglandular form is attended with some special symp- 
toms, owing to the deep seat of the inflammation, and to the fact that 
the pus when it forms is bound down by the thick tense mammary 
gland on one side, and the unyielding chest-wall on the other. The 
result is that the woman suffers extreme pain, and sometimes grave 
constitutional disturbance. The pus when formed approaches the 
surface slowly, and if the abscess is not opened the matter often finds 
egress by several orifices, which result in long fistulous tracts, which heal 
slowly, and which may result in profound exhaustion from the com- 
bined influence of the discharge and the irritation which they produce. 

The glandular form of mastitis is often attended with considerable 
constitutional disturbance. There is more febrile reaction than when 
the inflammation involves the subcutaneous connective tissue alone, 
while the pain is often severe. A number of abscesses sometimes form 
in succession in different portions of the gland. The swelling may 
become indolent, the induration continuing for weeks, and even months, 
almost unchanged. We have seen four months elapse before suppura- 
tion occurred, the woman in the meantime being troubled by the weight, 
tenderness, and lancinating pains in the diseased breast. During this 
period there is always a hope that the formation of pus can be pre- 
vented. — P.] 

The result of severe inflammation of the mamma, whether the abscess 
be single or multiple, usually is to destroy the nursing function of the 
gland. It is not that the secerning function of the gland is necessarily, 
or even generally, arrested ; but rather that the application of the child 
is attended with such pain and irritation, that it is at once impossible 
and undesirable. If the matter has been allowed to make its way to 
the surface, it often happens that a certain amount of sloughing occurs 
of the tissues surrounding, and immediately subjacent to, the orifice. 
By the same process, the continuity of the galactoferous tubes is also 
occasionally destroyed, and, as a consequence, a lacteal fistula is estab- 
lished. The continued secretion of milk in the unaffected portions of 



XXXVIII.] TREATMENT OF MAMMARY ABSCESS. 621 

the gland is sometimes a serious obstacle, in this and other ways, to the 
satisfactory issue of the case ; so that it is proper, in many instances, 
by friction or the external application of belladonna, to do what we can 
to arrest permanently the function of the mamma on the affected side. 
It sometimes happens that, by sympathy or otherwise, the other gland 
becomes similarly affected by inflammation and abscess, which, of 
course, makes the case a much more serious one. 

The treatment of inflammation of the mamma is thus, it need scarcely 
be observed, a matter of the highest importance. The initiatory phenom- 
ena of inflammation are to be combated by a careful management of 
the secretion, which should not be permitted to accumulate within the 
gland. This is, however, a matter of considerable difficulty ; for, while 
the application of the child, or the breast-pump, is often productive of 
irritation, rubbing of the breasts, which is the other alternative, is apt 
to increase it also. Cold or evaporating lotions are not to be depended 
upon ; so that we are often obliged at once to have recourse to leeches, 
fomentations, and poultices, just as we would in the case of the inflam- 
mation of any other gland. 

Should all our endeavors fail — as, unfortunately, they often will do 
— to arrest the inflammation, the earliest indications of the formation of 
pus are to be earnestly looked for. So soon as fluctuation can be de- 
tected, however faintly, the case may, we believe, often be cut short by 
early puncture, by means of an exploratory trocar or needle, which, 
by giving vent even to a few drops of pus, relieves tension, and often, 
apparently, arrests the course of the disease. Where fluctuation is 
already distinct, and near the surface, free incision should be practiced, 
on ordinary surgical principles, in the most depending part, so as to 
give immediate egress to the pus which has formed, making the open- 
ing — in order to avoid the lacteal tubes — in a direction radiating from 
the nipple. Both before and after the operation, great comfort is afforded 
to the woman by suspending the breast, by means of a handkerchief 
tied round the neck. In the case of a large abscess, the contraction of 
the cavity may be promoted by the application, externally, of broad 
strips of sticking-plaster, so adjusted as to contract the cavity within 
which the matter lies. In other respects, the affection is to be treated 
as an ordinary surgical lesion, while the general health must of course 
be carefully attended to. Whenever much trouble is encountered in 
the treatment of mammary abscess, we should not delay in ordering the 
removal of the child from the breast. 

[The treatment of mammary inflammation and abscess is a subject of 
great practical importance, and one about which the young practitioner 
cannot be too thoroughly informed. It is unfortunately one in regard 
to which the directions of text-books are too often vague and indefinite. 

For a number of years the editor, in his clinical lectures at the Phila- 
delphia Hospital, has taught the large classes of students who have 
honored him with their presence, to give personal attention to the con- 
dition of the breasts in every parturient woman under their care. Many 
nurses appear to think it their especial function to attend to these organs, 
and the writer has frequently known them to resent any interrogations 
of the accoucheur in regard to the breasts, as an unwarrantable inter- 



622 LACTATION. [CHAP. 

ference with their duties, while the young physician is too apt to accept 
their statements,. and to be restrained from making a personal examina- 
tion of the glands from motives of delicacy. As a consequence of this 
we have several times known mammary abscess to be discovered by the 
medical attendant too late to be aborted, or the conditions which give 
rise to it to escape his notice until too late to prevent these distressing 
results. We cannot therefore lay down a better practical rule for the 
guidance of the young obstetrician, than to make himself personally 
acquainted with the state of the breasts of his puerperal patient each 
day until the danger of mastitis is past. If the nurse is trusted, and 
information is received secondhand, he will surely have to regret his 
negligence sooner or later. 

The treatment of inflammation of the breast varies with the condi- 
tion of the patient and the stage of the disease. It may sometimes be 
aborted if treatment is commenced during the first twenty-four hours 
after the commencement of the disease. If the patient is vigorous, 
with high febrile reaction, and a full, strong pulse, we would not hesi- 
tate to administer a fever mixture containing ipecacuanha or even tar- 
tarized antimony. This may be safely given on the fourth or fifth day 
after confinement. The dose should be large enough to produce nausea, 
and diaphoresis, which will be followed by relief of pain, fall of tem- 
perature, and a diminution in the force and frequency of the pulse. 
At the same time the woman should take a saline cathartic. The gen- 
eral treatment of the subglandular variety does not differ materially 
from that of inflammation of the areolar tissue of the organ itself. 

In that form of inflammation in which the subcutaneous areolar tissue 
is involved, the local treatment is very important. The patient will 
sometimes be relieved by the application of leeches, but more frequently 
the local use of iodine and astringent solutions will be found to be suf- 
ficient. In order to be useful in aborting mammary inflammation, 
iodine must be applied early, before the end of the first twenty-four 
hours. Our own practice is to put it on freely, and then to cover the 
breast with cloths wet in a strong solution of acetate of lead and opium. 
If the patient is debilitated and weak, as is too often the case, depress- 
ing febrifuges are, of course, contraindicated. In these women a com- 
bination of neutral mixture and sweet spirits of nitre may be given 
with quinia in doses as large as the patient will bear, as recommended 
by Prof. Barker. Mr. Skey prefers dessertspoonful doses of Hux- 
ham's tincture, but the alcohol in this preparation sometimes disagrees 
with the stomach. In both strong and debilitated patients narcotics 
may be demanded to relieve pain and procure sleep. 

There are two questions in relation to the treatment of this stage of 
the disease which demand a passing notice. Most nurses and even a 
number of physicians imagine that benefit will be derived from rubbing 
the breast under these circumstances. It is supposed that this favors 
the discharge of the milk. We know of no more irrational treatment, 
and it cannot be too strongly condemned. If an abscess was forming 
in the cellular tissue of the arm, thigh, or any other part of the body, 
any intelligent physician or surgeon would at once prescribe rest. In 



XXXVIII.] TREATMENT OF MAMMARY ABSCESS. 623 

inflammation of the connective tissue of the breast, however, rubbing 
is sometimes advised as though the diseases of this organ were governed 
by laws different from those which control other parts of the body. 

The second matter is the supposed influence of the milk. There can 
be no doubt that the accumulation of this secretion in the glands leads 
to irritation and pain. When this is the case they should be emptied 
by sucking, performed either by the nurse or a puppy. If a breast- 
pump is employed it should be done with great care. We have known 
this instrument to cause an abscess many times, while we have very 
rarely known it prevent one. Dr. McClintock, of Dublin, believes 
that bad consequences rarely follow the accumulation of milk in the 
breasts, and no inconsiderable experience has led the editor to conclude 
that there is much truth in this opinion. The profession is not even 
now freed from the erroneous pathological views of Puzos and his fol- 
lowers, in which the retention of the milk played a prominent part. 
The mammary gland, it seems, has been supposed to be an exception 
to all secreting organs in the body in the tact that retention of its 
secretion is followed by inflammation. This is not the case with the 
kidneys, liver, or salivary glands. It is true, however, that the breasts 
differ from these organs, because their secretion is not constant, because 
they are called into functional activity more or less suddenly, and in a 
manner that predisposes the organs to irritation and inflammation. 
While, therefore, we wish to ascribe all due importance to the retention 
of the milk, and acknowledge that it may produce uneasiness and dis- 
comfort for the woman, we must protest against this being assigned a 
high place amongst the causes of mastitis, as well as against the alleged 
necessity of repeated and thoroughly emptying the organs in inflam- 
mation of the areolar tissue of the gland and that which is between it 
and the chest-walls. 

The treatment of the first stage of glandular inflammation of the 
breast is to be conducted upon the same general principles which 
govern the management of the other varieties. In this form gentle 
frictions are sometimes useful during the early stages by dislodging 
the thickened secretion of the gland. The hand should be covered 
with sweet oil or a solution of camphor in sweet oil, and the breast 
rubbed from the circumference towards the nipple. Prof. Barker says 
that he has found local applications of belladonna useful in this form 
of the disease. We have repeatedly used the extract applied to the 
breast on a cloth, but have never felt willing to conclude that much 
benefit results from its use. It certainly relieves pain, but it is doubt- 
ful whether it exerts much influence in diminishing the lacteal secretion. 
Dr. McClintock believes that it does not, and in cases in which he 
applied the cere-cloth to one breast and belladonna to the other in the 
same woman, the results on the two sides did not differ materially. 

If the measures just described do not arrest the progress of the in- 
flammation, it is the duty of the medical attendant to favor sup- 
puration by all the means at his command. It is important now to 
decide at what time the abscess should be opened. Most authors 
advise the early use of the lancet. The editor followed this advice for 
a number of years after commencing practice. He was often mortified 



624 LACTATION. [CHAP. 

and disappointed to find that after the discharge of the pus the process 
of repair did not go on at all rapidly. After having read Dr. McClin- 
tock's Clinical Memoirs on Diseases of Women, he concluded to try 
the plan of opening the abscess late, which that author recommends. 
The result of this practice has been in the highest degree satisfactory, 
and has led him to conclude that the popular idea that an abscess 
should " be ripe" before it is opened, is not entirely without foundation. 
The writer's practice is to watch the disease carefully during the sup- 
purative stage to prevent burrowing of the pus, but not to interfere 
unless this occurs, until the pus has approached the surface and the 
abscess is almost ready to open spontaneously. 

It may be said by some, that under these circumstances it is not 
necessary to use the bistoury at all. Clinical experience has disproved 
this. If left to open itself, sloughing of the skin and subcutaneous 
tissue may occur, leading to so much destruction of tissue that the 
recovery of the patient may be considerably delayed. The incised 
wound made by the knife preserves these tissues, while the evacuation 
of the abscess is followed by contraction of its cavity and rapid recovery 
of the patient. 

Subglandular abscesses are often exceptions to the rule that punctures 
should be made late. The pus in these is bound down between the 
large, tense gland in front, and the unyielding chest-walls behind. 
As a result, the patient suffers great pain, and yet it may be impossible 
to demonstrate the presence of pus by fluctuation. Under these cir- 
cumstances the breast should be seized and pulled forwards, when a 
fine trocar or an aspirating needle may be inserted between the gland 
and the thoracic wall in order to determine whether suppuration has or 
has not occurred. If it has, an incision should be made beneath the 
most dependent part of the gland. 

If cure does not follow the discharge of the pus, the pressure by ad- 
hesive strips, as recommended by the author, should be tried. 

During this stage of the disease the strength of the woman should 
be sustained by the use of good food and tonics. 

In certain cases, and especially in the subglandular variety, long 
fistulous tracts may follow an abscess. It is sometimes very difficult 
to heal these. To lay open the sinus it is necessary to cut through the 
whole thickness of the mammary gland, a procedure which is too serious 
to adopt. In a case of this kind, in which several fistulous sinuses 
followed an abscess between the gland and the chest-wall, we succeeded 
in effecting a cure by repeated injections of a solution of carbolic acid 
through a small trocar. In another instance a small piece of a stick of 
nitrate of silver was carried to the bottom of the sinus and left there. 
A cure followed. Many other remedies had been tried and had failed. 
Injections of iodine and of the sulphates of zinc and copper have been 
recommended under the same circumstances. Such sinuses can gen- 
erally be readily cured if treated on ordinary surgical principles. — P.] 

Excoriation and Fissure of the Nipple are affections so common, and 
withal so troublesome and painful, that their treatment should be a 
matter of interest to every careful and judicious practitioner. Although 
in themselves they are comparatively of little moment, they are of 



XXXVIII.] TREATMENT OF MAMMARY ABSCESS. 625 

peculiar importance as causes of the more serious affections which we 
have just been considering. Much may, undoubtedly be done in the 
way of prevention. Women, among the higher classes especially, should 
be instructed to lave the nipple, for many weeks before delivery, with 
some mild astringent or stimulant lotion, such as a weak solution of 
tannin in rose-water, or any dilute spirit. Yv T hen, however, excoriation 
has already taken place, the nurse should be instructed to apply some 
very gentle astringent at first — nothing being better than a strong infu- 
sion of tea. Failing this, the applications above recommended for pre- 
vention may be tried, or other similar medicaments, — of which there is 
an endless variety, — may be adopted. Care must, however, be taken 
to avoid such substances as may be prejudicial to the child, — such as 
acetate of lead ; and in all cases the application should be washed off 
very gently before the infant is put to the breast. In the more obsti- 
nate cases, the following will be found an admirable substitute: 

R. Acid. Tannici, .... gr. iij. 

Glycerin., ..... ( ^ss. 

Unguent. Cetacei, ad . . • £h 
Sig. To be used as directed. 

Fissures or chaps are even more troublesome than excoriation ; for, 
although they may at first be but trifling, every application of the child 
tends to tear them open, and undo the healing process of the interval. 
The above, or any similar ointment, will here also be found of great 
use, the best method of application being to introduce it into the chap 
by means of scraped lint. Should the margin of the fissure become 
callous, it may be necessary to apply freely the solid nitrate of silver. 
The nipple-guard, or shield, is, in all cases, useful in protecting the 
affected parts from the pressure of the dress ; and, when much pain is 
experienced in the act of suckling, the artificial nipple should be em- 
ployed, which will protect the parts from the violence to which they 
are often subjected by the vigorous sucking of a healthy child. In 
some obstinate cases, the irritation is such that it may ultimately be 
found necessary to remove the child permanently from the breast, and 
to obtain the services of a hired nurse. 

[Erosion, or fissure of the nipple, can sometimes be cured by the use 
of a solution of nitrate of silver, varying from ninety to one hundred 
and eighty grains to the ounce. The eroded or fissured surface should 
be carefully cleaned and the solution applied with a camel's hair brush. 
I am in the habit, if possible, of exposing the nipple to the direct rays 
of the sun, after the application, until the surface becomes black. The 
nitrate thus used forms a firm covering for the diseased surface. When 
it separates the physician will often have the satisfaction of finding his 
patient well. This method of treatment is applicable to fissures, 
erosions, and to ulcers, providing the last do not involve the orifices 
of the milk-ducts. If this is the case, the woman will have to quit 
nursing. — P.] 

40 



626 THE NEWLY BORN CHILD. [CHAP, 



CHAPTEK XXXIX. 

THE NEWLY BORN CHILD. 

MANAGEMENT OE THE COED— CLOTHING— CLEANLINESS — LIGHT AND AIR — COLOS- 
TRUM : IMPROPER USE OF LAXATIVES — THE MOTHER TO NURSE IE POSSIBLE — 
SELECTION OE HIRED NURSES : THEIR DIET AND REGIMEN — CAUSES OF DIFFI- 
CULTY IN SUCKING — CONGENITAL MALFORMATIONS — THE EXCRETORY FUNC- 
TIONS — DIARRHCEA : SIMPLE OR " CATARRHAL," AND INFLAMMATORY OR "DYS- 
ENTERIC" varieties: treatment of each — constipation: management 

OF— ICTERUS NEONATORUM — THRUSH — ARTIFICIAL FEEDING: SUBSTITUTES 
FOR BREAST-MILK : COW'S MILK, DILUTED AND SWEETENED: NURSING-BOT- 
TLES: NURSE TO BE PROCURED IF CHILD DOES NOT THRIVE: OTHER ARTICLES 
OF DIET: LIEBIG'S FOOD FOR INFANTS — WEANING — DENTITION. 

The subject of this chapter has reference to certain points relative 
to the management of the infant after its birth, and the treatment of 
some of the more common ailments which are apt to attack it during 
the first weeks or months of its existence. 

So soon as the nurse has, after the termination of labor, attended to 
those matters of detail which are essential to the comfort and safety of 
the mother, her attention is naturally turned to the child, which is 
then to be washed and dressed. The first point to be looked to after 
it has been thoroughly cleansed by soap and warm water, is the stump 
of the cord, which undergoes a process of putrefaction, and, ultimately, 
in the course of a few days, separates at the cutaneous margin of the 
umbilicus. The decomposition of the tissues of the cord takes the form 
rather of withering than of moist putrefaction ; but, before it drops off, 
there is generally more or less of the odor characteristic of the process 
which is going on. To obviate this, it has long been the practice to 
wrap the cord in cotton or linen, passing the stump, in the first in- 
stance, through a hole which has been burnt in the cloth, so as to secure 
the antiseptic action of the charred margin. This, of course, is not es- 
sential, but is, undoubtedly, favorable to cleanliness ; and the dressing 
may be renewed at proper intervals, to be determined by the amount 
of moisture which makes its appearance, and which will depend, in a 
great measure, on the thickness of the cord. It occasionally happens, 
after the stump has dropped off, that the navel remains gaping and 
raw, sometimes with ulceration, and even sloughing of the margins, a 
condition which is always serious and sometimes fatal. For some time 
after the separation is complete, there remains a tendency, more or less 
marked, to the formation of umbilical hernia. This is particularly 
noticeable in the case of children who are subject to screaming fits, and 
to the straining which accompanies them; and is in all cases to be 
guarded against by the application over the umbilicus of a soft pad, 






XXXIX.] CLOTHING. 627 

formed by several folds of linen, which is retained in position by a 
broad bandage of flannel with which the abdomen of the child is 
swathed. By increase in the thickness or otherwise, the pad may be 
so modified, in cases in which protrusion is threatened, as to retain the 
bowel within the abdominal cavity. 

[Dr. William Goodell prevents many of the accidents which may 
arise during the separation of the cord by the following modification of 
Dr. A. F. A. King's method of managing that organ. When the 
child is ready for removal, Dr. G. cuts the cord at the usual place, 
and then seizes it between the thumb and forefinger of the left hand, 
close to the umbilicus. Holding it firmly in this position, he then 
proceeds to "strip" it with the thumb and index finger of the right 
hand. 

By this means all of the blood and much of the gelatine of Wharton 
is removed. If there are accumulations of the latter in projections of 
the funis, these lobules are to be nicked with the scissors, and their con- 
tents squeezed out. The pressure near the umbilicus should now be 
temporarily suspended, when the internal portions of the vessels col- 
lapse. The part is now subjected to a second stripping, after which, 
haemorrhage having ceased, it is tied in the usual manner. It is now 
left entirely free without any dressing whatever. The result is that it 
separates without any bad smell whatever, falling off " like a ripe fruit, 
without leaving a raw stump." 

Dr. Goodell states that since he has adopted this method of treating 
the cord in the Preston Retreat, the astringent lotions, which he for- 
merly had frequent occasion to use, are never called for ; " but that 
since adopting this new method, out of more than two hundred infants 
not a single one had had a pouting, angry-looking, or purulent um- 
bilicus; nor had any one suffered from fungoid vegetations or umbilical 
hernia."— P.] 

The clothing of the child is in some measure to be regulated with 
reference to season and climate. In all cases, however, it is to be re- 
membered that birth almost necessarily involves a sudden and consid- 
erable diminution of temperature. Any failure, therefore, in the vigor 
of the circulation, such as may be anticipated in premature delivery, is 
very likely to be attended with a corresponding diminution in the 
temperature of the body, which not imfrequently involves great and 
sudden risk to the life of the child. The maintenance, therefore, at 
first, of an equable temperature is of the highest importance, and is 
universally recognized. On these grounds, flannel — which, as a bad 
conductor of heat, tends materially to sustain a steady temperature — 
is, to a great extent, employed in the clothing of infants. It has also 
the advantage of absorbing the discharges to some extent, and thus 
preventing any irritation which may arise from their prolonged contact 
with the cutaneous surface. While the infant is thus wrapped in its 
swaddling-clothes, care should be taken so to arrange them as to admit 
of free movement of the limbs from the first. It was at one time sup- 
posed that the head of the child should be protected as carefully as its 
trunk ; but the general practice now is rather to keep the head cool, so 
that, in this country at least, it is the exception rather than the rule, 



628 THE NEWLY BORN CHILD. [CHAP. 

to put even a light cap on the head of a child. Important as the 
maintenance of an equable temperature is in all cases, it is much more 
so when the infant is brought prematurely into the world, — when it is 
necessary, in order to maintain the circulation, to swathe the limbs in 
cotton-wool, at least during the first few weeks after birth. In all 
cases, for the first few months, the heat of the trunk and lower limbs 
is further insured by the use of long clothes. 

Strict cleanliness is essential to the well-being of the infant; and in 
nothing is the difference between a good and careless nurse more clearly 
evidenced than by the management of the napkins, and the protection of 
the parts from the contact of urinary and fecal discharges. Neglect 
here frequently gives rise to troublesome excoriation of the nates, or in 
the flexure of the groins; and nothing, perhaps, is of more importance 
than that the child should be kept dry as well as clean. The use of 
the warm bath is universal; but, as regards the frequency with which 
it is to be employed, some degree of discretion may be exercised in indi- 
vidual cases. Many nurses, after the first few days, undress and bathe 
the infant, if perfectly healthy, night and morning, and apparently 
with benefit as well as with safety. Caution should, however, in this 
respect, always be enjoined, as, in some instances, too frequent bathing 
seems to produce an exhausting effect ; and, in the case of feeble or sick 
children, it may only be possible to insure cleanliness by rapid spong- 
ing, while the bath is either avoided altogether, or repeated only at 
intervals of two or three days. During the first six weeks, the child 
should not be permitted to remain in the bath for more than two or 
three minutes. 

Light and air are as essential to the growth of a child as to that of a 
plant. At first, however, caution is, even in these respects, necessary. 
A dim and subdued light is thus more suitable, until the organs of 
vision become, in some degree, accustomed to the new stimulus; and, 
in like manner, until the new function of respiration, and the mainten- 
ance of temperature, are efficiently and vigorously discharged, we must 
take care, in our anxiety for pure air, not to expose the infant to vicis- 
situdes of temperature. In the warm weather of summer, it may be 
taken out somewhat earlier, although, as a rule, it is better not to carry 
the child out of doors before the end of the second week; but, when 
this stage has been reached, nothing, perhaps, is of greater importance, 
or has a greater effect on the health and development of the infant, than 
its daily exposure in the open air, clothed according to the requirements 
of the season. 

During the weeks which immediately succeed its birth, the infant 
passes the greater portion of its time, by day as well as by night, in 
sleep; but in this respect there is great variety, even with healthy 
children. For example, it often happens that they sleep quietly and 
almost continuously during the day, awakening only at intervals to go 
to the breast, while at night they are wakeful and restless. This, after 
a time, is often rectified by the management of an intelligent nurse, who, 
by keeping the child awake during a part of the day, or it may be by 
bathing it at night instead of the morning, succeeds in breaking the 
habit, to the great relief and comfort of the mother, who otherwise has 



XXXIX.] SELECTION OF NURSES. 629 

her rest broken and her nursing powers impaired. Sleep is certainly 
encouraged, and often very markedly so, by the daily exposure to the 
open air. 

The child should, for various reasons — some of which have been pre- 
viously mentioned — be put early to the breast. The laxative action of 
the Colostrum generally produces the discharge from the bowels of the 
dark-colored meconium which is lodged there. It is too much the 
habit of nurses to dose the infant w T ith castor oil, under the idea that 
it is necessary in order to set up the execretory function of the bowels. 
This practice is no less deleterious in its results than it is irrational in 
theory; and, in point of fact, there is no more fruitful cause of subse- 
quent gastric irritation and intestinal derangement. The accoucheur 
should therefore put his absolute veto on any such treatment without 
his sanction, at least during the period while he remains in attendance. 
It is no doubt more frequently necessary when the child is being nour- 
ished with substitutes for breast-milk, but in the great majority of cases, 
it is, to say the least, perfectly unnecessary. Another very general 
practice is, during the first two days, before the secretion of milk has 
been thoroughly established, to feed the child with sugar and water. 
The effect of this, too, is often the reverse of beneficial, as this syrup is 
not only unsuitable to the nourishment of a newly born child, but it is 
also apt to derange the functions and to give rise to ulterior ailments, 
which may be the cause both of trouble and anxiety. A mixture of 
cow's milk and water, with a very small proportion of sugar, — or, better 
still, of sugar of milk, — is a more eligible substitute ; but so soon as the 
milk becomes abundant, all such methods should be abandoned for the 
natural secretion of the mother's breast. 

Every mother should be encouraged to nurse her own offspring, un- 
less under certain exceptional conditions which have been referred to in 
the preceding chapter. For not only is this to her advantage ultimately, 
by preventing too frequent pregnancies, but it is to the advantage of the 
child, by furnishing it with what nature has specially provided for its 
support. What has already been said with reference to the function of 
lactation, is sufficient clearly to show how important is the management 
of that function, in its bearing upon the child, no less than upon the 
mother. Care should be taken from the beginning to put the child to 
the breast at something like fixed intervals, gradually extending the 
periods from two to four hours, as has already been explained. This, 
by allowing the breasts to fill, and permitting the mother satisfactory 
and continuous sleep, goes some way to maintain the quality of the 
milk; while, as regards the child, it gives the digestive and assimila- 
tive functions time to rest. There is certainly no more fertile cause of 
the minor digestive derangements, than the habits which prevail among 
the ignorant, of constantly putting the infant to the breast, as the ready 
method of cure for restlessness or screaming fits. 

Various circumstances, — sometimes occurring quite unexpectedly, — 
may render it impossible that the mother can nurse her infant. When 
this is the case, the medical attendant should always recommend that 
the services of a hired nurse be at once obtained ; and, if this recom- 
mendation be acted upon, the duty of selecting a nurse devolves natu- 



frSO THE NEWLY BORN CHILD. [CHAP. 

rally upon him. This is a matter of no small importance. From 
what has been said in the preceding chapter as to the nutritive value 
of the milk in different cases, it will be obvious that some caution must 
be exercised, and especially that we should not too hurriedly infer, 
either from the abundance or the apparent richness of the milk, that 
the woman is to be looked upon with confidence, as necessarily a good 
nurse. There are certain other matters in regard to which it is our 
duty to inquire. We thus look narrowly, and as a matter of course, 
to the general health, circumstances, and age of the applicant ; a per- 
fectly healthy young woman, from a country district, and between the 
ages of eighteen and twenty-eight, being generally preferred. With 
reference to general health, some have attached considerable importance 
to the state of the teeth, as affording a reliable indication ; and, al- 
though this has certainly been exaggerated, there can be no doubt that 
the early loss of the teeth, and especially of the front teeth, by decay, 
is so far an unfavorable symptom. It is obviously our duty to deter- 
mine, in so far as this may be possible, whether she is the subject of 
any disease which may be transmissible to the child. Any evidence, 
should it but amount to a suspicion, of serious organic disease, and es- 
pecially of a phthisical tendency, may be held to warrant rejection. 
Unfortunately, the circumstances are such, in many cases, as to admit 
of, at least, the possibility of a syphilitic taint, and this is, therefore, 
a point in regard to which we should very specially be on our guard. 
To glance at the throat, the skin, the glands of the neck, and the hair, 
are, on this account, matters almost of routine in such investigations. 
We should also examine the breasts, — not only with regard to their 
secretion, but as to the state of the nipple; and the presence of severe 
excoriations, and still more of fissures at the base of the nipple, are to 
be held as unfavorable conditions. And this for various reasons, — 
one of the most important of which is the fact, that we can have no 
confidence that she will prove a zealous and attentive nurse, if any 
application of the infant to the breast is attended with discomfort or 
suffering. If we have a choice in the matter, we should also select a 
nurse whose condition, as regards the age of the milk, may be as nearly 
as possible that of the mother, and if any change is permitted, it is 
better that she should have been confined a little later than before her. 
It is always a matter of importance to be able to see the child of the 
nurse; and its condition may often be held to indicate the nutritive 
value of the milk. There are, of course, other matters, which have 
reference to the character and disposition of the woman, or to the fact 
of her having had previous experience in the rearing of children, 
which may be held as being of no small importance ; but these are, 
perhaps, questions which do not so immediately come under the cogni- 
zance of the medical attendant. 

The diet and regimen of hired nurses is a matter to which some 
prominence should be given. It is, indeed, of greater importance in 
this case than in that of the mother, that no overfeeding or other 
similar imprudence should be permitted. The simple rule in all such 
cases should be that the woman is supplied with plain and easily di- 
gested food, which, in point of quantity, should be ample, but, at the 



XXXIX.] CONGENITAL MALFORMATIONS. 631 

same time, not more than is requisite for the maintenance of perfect 
health. If, with the view of contributing to the health and vigor of 
the child, the nurse is plied, as is often the case, with strong soups, 
gruel, and stimulating articles of diet, at short intervals during the 
day, the result is likely to be exactly the reverse of what is anticipated, 
and the child suffers from overrichness of the milk, while the nurse 
becomes rapidly fattened. No rule can be laid down, however, as to 
the diet suitable for nurses, beyond this, — that a large proportion of 
their food should consist in the simple and possibly frugal fare to 
which they have been accustomed. In this way the danger to which 
we have referred may always be avoided, but everything will, of course, 
depend upon the habits of the country or district from which the nurse 
has been procured. In the rural districts of Scotland, for example, 
oatmeal, in the form of porridge, and generally eaten with buttermilk, 
is one of the most important items in the daily food of the masses, 
and is well known to be admirably adapted for women who are nurs- 
ing, although it was some years ago stated in a report presented to 
Parliament on the dietary of the English prisons that the food referred 
to was " similar to what is used in England for the fattening of pigs." 
The habits of the English peasantry and of the lower classes in all 
large towns will require to be taken into consideration in the regula- 
tion of the diet. With us, beer and other malt liquors are seldom 
used, and are, therefore, quite unnecessary ; indeed it may be said that 
if a woman cannot nurse without stimulants, her assistance may be 
dispensed with. But, in England, where the daily use of beer is all 
but universal, this, to which the woman has become accustomed, should 
always be given, as probably essential to the maintenance of her phys- 
ical condition. 

The infant, if healthy, instinctively seizes the nipple from the first 
and sucks vigorously, and indeed has often been seen to suck the finger 
of the accoucheur before the trunk was born. It is not, however, always 
so. The difficulty arises, in many cases, from a peculiarity in the con- 
formation of the nipple, which may either be unusually small, or — 
what is more common — has been carelessly allowed to be pressed in by 
the dress during pregnancy. This may generally be got over by having 
the nipple drawn out by the nurse or by a strong child, by the breast- 
pump, or by a soda-water bottle used like a cupping-glass, care being 
taken not to permit the parts to relapse into their former condition. 
With care and proper management on the part of the nurse, this diffi- 
culty is seldom a serious one. The child may, in other cases, especially 
when born prematurely, be unable by weakness to take the breast, a 
condition which is highly unsatisfactory. The woman, in these cases, 
should milk her breast into the mouth of the child, when it will gen- 
erally swallow the milk as it flows; or she may drain it off by the 
pump, and feed the infant by a spoon ; but the objection to this is that 
it is a bad plan to use a spoon if it can be avoided, for the child thus 
becomes accustomed to the spoon, and still further loses the instinct for 
the nipple. An idea extensively prevails among the lower classes that 
when a child has difficulty in sucking, or refuses the breast, it is 
" tongue-tied," but this is an obvious error. It, no doubt, does happen, 



632 THE NEWLY BORN CHILD. [CHAP. 

although very rarely, that the fnenum of the tongue is too short, or 
attached too far forward, but in ordinary practice, it will probably not 
occur oftener than once in a lifetime that the accoucheur is obliged to 
divide the frsenum for this variety of congenital malformation. 

It is the duty of the accoucheur to examine the child after its birth, 
and to inquire on his subsequent visits as to the various functions, in 
order that congenital malformations may not be overlooked. It may 
thus become evident either immediately or shortly after birth that the 
child is affected with some peculiarity which must be remedied in order 
to save its life. Such malformations as harelip fall more properly iuto 
the domain of surgery, but in the case of an imperforate condition of 
the anus or urethra, the general practitioner must be prepared to act 
promptly. In the former, an operation is necessary by incision in the 
direction of the rectum, or it may even be necessary in extreme cases to 
form an artificial anus. Imperforate urethra, again, is rare, probably 
for the reason which is pointed out by Burns, that " generally the canal 
opens, in supposed cases of imperfo ration, about midway between the 
scrotum and glans penis;" and the result of experience seems to be that 
perforation of the glans seldom succeeds, so that it would probably be 
better to cut down upon the urethra than attempt to find its extremity. 
It may be necessary, even where there is no closure, to pass a probe or 
a very small elastic catheter into the bladder, in consequence of retention. 

We are often told, a considerable time after delivery, that the child 
has not made water. On such information, however, we must never 
act, unless there is some evidence of distension of the bladder. The 
urine is often voided in the bath, and thus escapes the notice of the 
nurse; and if retained for a longer period than usual the application of 
cold water over the hypogaster, or a teaspoonful of cold water given by 
the mouth, will generally have the effect of causing contraction of the 
viscus. Nor is a tardy action of the bowels to be held as necessarily in- 
dicating the administration of laxatives; for, in this as in the other 
case, nature generally will, if left to herself, bring the function into per- 
fect order without any extraneous assistance. We must, in like manner, 
be cautious in the administration of such drugs as are usually employed 
in the treatment of diarrhoea. Be it remembered, in the first place, that 
there is, in healthy children, the greatest possible difference in the 
manner in which the bowels discharge their functions. In one, the 
frequency and the character of the evacuations may seem to amount to 
diarrhoea, and in another the dejections are habitually costive; but so 
long as the infant remains in perfect health, drugs of all kinds are to 
be scrupulously withheld. In many cases, we may suceeed in produc- 
ing the effect which we desire through the mother, but we can scarcely 
be too cautious in any attempt to act directly upon the child. 

Diarrhoea, although of more frequent occurrence during the process 
of dentition, may happen at any period subsequent to the birth of the 
child. A strict attention to the directions which have been given above 
will suffice, as we have reason to believe, in most cases, to avert many 
special conditions which are apt to lead to this troublesome affection ; 
but even under circumstances the most favorable, the diarrhoea of infants 
is only too familiar from its frequent occurrence. The ordinary " simple " 



XXXIX.] DIARRHCEA. 633 

or catarrhal variety of diarrhoea, which is the most frequent, is also the 
least serious; but, in the case of the newly born child, the enormous 
quantity which is sometimes poured out may reduce the strength of a 
puny infant so rapidly, as to place it in a most critical condition in the 
course of a few hours, without any evidence whatever of inflammatory 
action. If the action of the bowels is accompanied with obstinate 
vomiting, the case may be looked upon as much more alarming in its 
nature; but simple, uncomplicated diarrhoea is seldom dangerous, unless 
it passes into the more serious variety. The appearance of the discharge, 
as seen on the napkins, varies greatly, from a watery and almost color- 
less fluid to a slimy matter, which may be frothy or bright-yellow like 
the yolk of an egg, and in other cases green, mixed with fragments of 
curdled milk, and possibly streaked with blood. A much more alarm- 
ing variety is where the diarrhoea takes the "inflammatory" or "dysen- 
teric" form, when it is generally attended with corresponding gastric 
disturbance, with a marked increase in the temperature and in the fre- 
quency of the pulse. Between the extremes, the varieties in individual 
cases are endless, and, consequently, the treatment which may be held 
as applicable in each must vary in a corresponding degree. 

Unless on an emergency arising from the violence of the symptoms, 
we should always, in very young children, try the milder measures first. 
A teaspoon ful of lime-water given with a little boiled cow's milk, or 
with the milk of the mother, has often a marked and immediate effect. 
The number of cases which may be traced to imprudence in the dietary 
of the mother or the nurse is, we believe, much greater than is generally 
supposed ; and we would, therefore, recommend that this should always 
be inquired into, and, if necessary, modified without delay. Should 
the presence of blood in the stools, an appearance of tenesmus, and 
general inflammatory symptoms, indicate the existence of the more 
serious form, nothing has a better effect, if it can be retained, than 
castor oil with a single drop of laudanum. Among other available 
astringents are the tinctures of catechu or kino, which may be admin- 
istered in the usual way with chalk mixture, to which may be added, 
in the event of flatulence being a concomitant symptom, a proper pro- 
portion of peppermint or pennyroyal water. The young practitioner 
cannot be too cautious in the use of opium in any of its forms ; for, 
although he may thus succeed in checking the discharge, the benefit 
which results is often temporary in its character, and, indeed, the 
symptoms would sometimes seem to come on after opium worse than 
before. The bright-green appearance of the evacuations, to which 
reference has already been made, is not to be looked upon as necessarily 
a very unfavorable condition ; and one object in mentioning the fact at 
this place is that this condition seems somewhat too frequently to be 
admitted as a reason for the administration of powerful drugs. When, 
at a somewhat more advanced age, the child is being fed, an alteration 
in its diet and a recurrence to the simpler nourishment of the early 
months will often suffice to arrest the symptoms. 

In the case of habitual Constipation, a favorite remedy is manna 
given with milk. Nothing is easier, of course, than to move the 
bowels, either by this, by castor oil, or by any other laxative ; but it 



634 THE NEWLY BORN CHILD. [CHAP. 

will generally be found that if we begin with laxatives, they must be 
continued. On this account, many nurses prefer to use an injection of 
soap — or to pass into the rectum a small piece of soap, which is cut so 
as to admit of its easy introduction. We cannot doubt, however, that 
a large proportion of such cases are unnecessarily treated, and would 
do quite well if left alone. 

It is only possible for us very briefly to notice a few of the more 
common ailments which affect the infant shortly after its birth. The 
vulgar nomenclature of these disorders has unfortunately shrouded the 
subject with an obscurity, which the limited knowledge of most mid- 
wives rather tends to deepen. Such terms as " hives " and " gum" are 
familiar in the mouths of experienced matrons of the lower class ; but, 
unfortunately, indicate nothing — or, rather, so many different things, 
that the words have lost any scientific signification which they may 
have had. One of the most common of the affections alluded to is 
what is known as Icterus Neonatorum. It was at one time generally 
supposed that this very common affection indicated some serious patho- 
logical condition, the liver as well as its function being believed to be 
implicated. The chief symptom of this familiar affection is a tinging, 
more or less marked, of the skin, which becomes of a yellow color. 
In immature or feeble children, this gradually deepens, and distinctly 
affects the conjunctiva; while the colorless condition of the evacuations 
points still more clearly to the analogy which subsists between this and 
ordinary jaundice. Although it may be too much to suppose, as some 
have done, that this is a " perfectly natural state, in which the skin 
and other secreting organs are called on for a few days to assist in dis- 
posing of the bile, until the demand for it to minister to the digestive 
function becomes equal to its abundant supply," we may, in the case 
of a child otherwise healthy, look upon the phenomenon in question 
without the slightest apprehension. If excessive, it is usual to give a 
grain of Hydrarg. c. Greta, followed by a small dose of castor oil ; but 
even this is rarely necessary, as the discoloration generally passes off 
spontaneously, and almost as rapidly as it came on. 

We may here briefly advert to one other of the affections of infancy, 
which is generally, although not invariably, associated with impaired 
nutrition. This is familiarly known under the name of Thrush. If 
we look into the mouths of children who are the subjects of this affec- 
tion, we observe on the surface of the mucous membrane of the tongue, 
lips, and cheeks, a number of small, circular, white spots, which appear 
at the first glance as if minute portions of curdled milk had adhered to 
the surfaces in question. A more careful examination shows either 
that they cannot be detached, or, if so, that the subjacent surface pre- 
sents an eroded appearance. Microscopic researches, as to the nature 
of this affection, have proved that it is due to the presence of a crypto- 
gamic vegetation, which is, more or less obviously, associated w 7 ith 
derangement of the digestive functions. It has been conclusively 
demonstrated that this may be transplanted from one mucous surface 
to another • and we have seen more than one case in which a trouble- 
some affection of the nipples, and of the contiguous cutaneous surface, 
had apparently been directly produced by it. The treatment will con- 



XXXIX.] , SUBSTITUTES FOR BREAST-MILK. 635 

sist in such measures as may remedy the digestive ailment upon which 
it is presumed to depend ; and, at the same time, the local affection is 
to be treated by the application of a solution of twenty grains of borax 
in an ounce of water, which may be replaced in the more obdurate 
cases by a solution of nitrate of silver, of four grains to the ounce of 
distilled water. 

[The most efficient remedy which we have ever employed for the 
relief of this common affection, is a saturated solution of the sulphite 
of soda, which may be applied to the mucous membrane of the mouth 
by means of a soft rag, several times a day. At the same time the 
child should be allowed to swallow one or two grains of the drug in 
solution. The good results of this method of treatment manifest them- 
selves in a short time. — P.] 

In cases in which the parents are not in circumstances to afford the 
services of a wet-nurse, and in other instances in which there is an un- 
conquerable repugnance to the employment of a hired nurse, it may be 
necessary, from the first, to rear the child by the use of certain substi- 
tutes for breast-milk — its natural food. Our primary object must, 
therefore, be to provide such nourishment for the infantas may, chemi- 
cally and otherwise, most nearly resemble that which nature provides. 
Ass's or goat's milk probably approach in their composition nearest 
to the secretion of the mammary gland in the human female, and, if 
obtainable, may on that account be preferred. The objection to the 
milk of the cow is, that it is so much richer in the corpuscular element 
that, if given undiluted to a young infant, it rarely fails to engender 
some form of gastro-intestinal disorder. This, however, is, in the vast 
majority of cases, the best substitute which is within reach; and, as the 
fundamental objection to its employment is its richness, experience has 
shown that simple dilution with water furnishes a material by which 
hundreds of thousands of infants are, without difficulty, reared in this 
country. Still, even under circumstances the most favorable, it is 
obvious that the best substitutes for breast-milk are open to objection; 
and we are, therefore, not astonished to find the infants, thus artificially 
reared, are more liable to disease, and more likely to succumb to it. 
On this account alone, were there no other argument in favor of it, it is 
the duty of the accoucheur to insist, as far as he can, upon all children 
being reared at the breast ; and, in the case of children born prema- 
turely, he should absolutely refuse his sanction to any proposal other- 
wise to nourish it. 

The amount of water to be added to cow's milk will, of course, depend 
upon its quality. If rich and pure, an equal bulk, or even more, of 
water may be added, but it is, in towns at least, rarely necessary to add 
more than a third of water, in order to reduce an average specimen to 
the extent which is requisite. Such a mixture as this is, as compared 
with human milk, deficient in the saccharine element, and it is on that 
account usual to sweeten it with the ordinary sugar of commerce; but 
what should always be preferred, when it is within reach, is the sugar 
of milk, which is now prepared in considerable quantities for this pur- 
pose from the whey of cow's milk. The mixture should always be 
given w r arm, about blood heat, to which temperature, therefore, it must 
be artificially raised. A great variety of nursing-bottles has been de- 



636 THE NEWLY BORN CHILD. [CHAP. 

vised, most of them being simple as well as ingenious in construction, 
with the object of enabling the child to suck from an artificial nipple 
at the extremity of the apparatus. [One of the simplest possible con- 
struction should always be selected. This cannot be insisted upon too 
strongly. All devices intended to save nurses should be studiously 
avoided, owing to the difficulty in keeping them clean. A plain bottle 
with an ordinary artificial nipple is the only nursing apparatus that 
should be allowed. — P.] In a word, our whole object is — when a child 
has to be reared artificially — to assimilate all the conditions as nearly as 
possible to those which exist when the natural source is available. The 
success of bottle-feeding depends very greatly upon the care and expe- 
rience of the mother or nurse, and upon nothing does the ultimate result 
hinge more than upon strict attention to cleanliness. It is well known 
that it is more difficult thus to rear a child in summer than in winter, 
from the rapidity with which, in the former case, the temperature acts 
upon the milk. It is also well known that, when the apparatus is not 
kept scrupulously clean, small particles of curd are apt to accumulate 
within it or the tube, and these again, if swallowed by the infant, are 
more than likely to excite gastric or intestinal disturbance; but these 
difficulties are fortunately in a large majority of cases completely over- 
come, and the infants, if originally vigorous and mature, are often 
pictures of health. 

So long as, under such alimentation, the functions of digestion and 
assimilation are perfectly discharged, we may well be content with the 
condition of the child; but when — as occurs in a certain proportion of 
cases — the child pines and is not thriving, the digestion is impaired, or 
obstinate diarrhoea supervenes, we must, without delay, adopt means for 
its relief. It is usual, when at all practicable, to obtain the milk for an 
infant from one cow, and what, in the condition alluded to, has often 
been found sufficient is simply to change the cow, as, under other cir- 
cumstances, we might do with the nurse. Bat, when this and other 
simple remedial measures fail in producing an effect, and the infant con- 
tinues to droop, we should lose no time in urging that a nurse be 
obtained at once. In many cases this is delayed until the condition of 
the child becomes critical, and the assistance of the nurse, when event- 
ually obtained, is too late to rally the little sufferer from the condition 
into which it has fallen; and, in fact, this question often devolves a 
serious responsibility upon the medical attendant, who is certainly 
blameworthy if he fail to interpose his authority before it is too late. 

The period at which other articles of food are to be permitted to the 
child, is another question in regard to which we are often expected to 
express an opinion. Much will no doubt depend upon the health of 
the mother, and the abundance or otherwise of the lacteal secretion, but 
Ave have great reason to believe that the tendency is considerably to 
anticipate the period at which a variety of diet may safely be permitted. 
We think we are justified in concluding that, for the first three months, 
milk, and milk alone, is the best as well as the most natural food for 
the child ; but, in this as in most other respects, the safest and most 
reliable indication is to be found in the condition of the child itself. 
So long, indeed, as its appearance and development, the manner in 
which its functions are discharged, and the extent to which it enjoys 



xxxix.] liebig's food for infants. 637 

refreshing and quiet sleep, indicate perfect health, too much caution 
cannot be exercised in sanctioning any change, unless indeed the in- 
terests of the mother should render it imperative. 

Of the many substances which have been employed as substitutes 
for, or supplementary to, milk in the alimentation of infants, nothing 
has, perhaps, of late years, attracted more attention than the Food for 
Infants which was devised as the result of much original research by 
Baron Liebig. 1 Boiled bread and milk, arrowroot, corn flour, and a 
host of simple and easily digested substances are extensively employed, 
the articles selected depending more upon the fancy or prejudice of the 
nurse than on any marked superiority of one over another. Nothing, 
we are assured, is better than rusks, if they can be obtained of good 
quality ; and if well made they require no boiling, but are to be cov- 
ered for a minute or two with boiling water, which is then poured off, 
and milk or cream, with a very little sugar, added before it is broken 
up. When the child grows older, a little carefully made chicken soup 
or beef tea may be given twice a week ; and, by thus adopting each 
change of diet with caution, it may be gradually altered so as to suit 
the increasing requirements of a higher stage of development. 

Weaning. — The separation of the child from the mother involves 
something of a crisis in its existence, and is generally, as might be ex- 
pected, attended with more or less constitutional disturbance. The 
condition of the mother must necessarily, as has already been shown, 
point clearly in many cases to the conclusion that the infant should, in 
her interest, be at once withdrawn. But, when circumstances are in 
all respects favorable, it has in every instance to be determined what 
is the proper period for weaning — what time, in the interests of both, 
is to be selected for the severance of that physiological tie which binds 

1 This may be obtained in any quantity, carefully prepared by ^ninent chemists, 
but as its price puts it beyond the reach of the humbler classes, we are induced to 
borrow some sentences from a little pamphlet published on this subject by a lady, 
whose main object was to bring the food within the reach of all. " The ingredients 
required," she writes, " are the following; 

Malt, ^ oz. 

Second Flour, J oz. 

Skimmed Milk, . . . . . . 6 oz. 

Water, 1 oz. 

Bicarbonate of Potash, 1\ grains. 

"I may mention here that, after picking out other seeds which are often found 
among malt, and which may be injurious, the malt should be crushed in a mortar or 
ground in a coffee-mill. Mix all the ingredients together, and put them in a pan 
thoroughly clean, boil for six or eight minutes, stirring all the time; remove from 
the fire, strain through an ordinary sieve or piece of muslin, and give to the child 
through a feeding-bottle. See that the holes in the nipple of the tube are large 
enough to admit of the food passing through them, and that it be not given too 
warm. The above quantity daily will be found sufficient for an infant for the first 
few days; but very soon it will have to be increased to two or three cupfuls, and 
more. For a newborn child who has to be fed entirely on this food, it should be 
made at first half milk and half water. Use skimmed milk ; new milk is too 
strong. If properly made, the food should be quite sweet, and taste as though 
sugar had been put into it; but sugar must on no account be used. The quantity 
required for twenty-four hours may be made at once, and heated for use as required. 
Malt can be had at the bakers', who use it for making bread, it is dry and slightly 
crushed, and should be ground fine before using ; this can be done in an ordinary 
coffee-mill." 



638 THE NEWLY BORN CHILD. [CHAP. 

together the mother and her offspring. It is very unusual to wait until 
the occurrence of pregnancy or the condition otherwise of the mother, 
show clearly that she is no longer able to supply proper nutriment to 
the child. Were we even to look at the case without any reference 
whatever to the maintenance of her health, a very little reflection 
should suffice to show that nursing beyond a certain average period is 
little likely to maintain the health or well-being of the infant; but, as 
in this matter, the interests of the mother are in a sense inseparable 
from those of the child, it is sometimes a question involving both care 
and discrimination absolutely to fix the time for weaning. 

It has frequently been asserted that the natural period for separating 
the child from the mother is on the completion of the process of denti- 
tion ; and it may, perhaps, be admitted that, theoretically, the idea is 
not destitute of validity. Every one knows, however, that, although 
it may be possible to nurse for two years — the period at which the first 
dentition is usually completed — the amount of milk secreted ceases 
long before that to be sufficient for the nourishment of the child. 
Indeed, the cases are exceptional in which a woman is able to suckle 
her child, without assistance in the way of extra aliment, for a longer 
period than ten months ; and a large proportion of mothers and nurses 
require supplementary aid much sooner than this. In cases, therefore, 
of protracted lactation, the breast-milk is generally an insignificant 
portion of the total nourishment which is given to the child ; and we 
can scarcely doubt that, under such circumstances, weaning might have 
long before been effected, in the interest of the infant, as well as in that 
of the mother. For while, on the one hand, a deteriorated lacteal se- 
cretion can scarcely fail to exercise a pernicious influence on the child ; 
so, on the other hand, a long-continued drain on the system is seldom 
without its effect on the health of the nurse. 

With a healthy and vigorous nurse, it is better that the child should 
have nothing but what she can afford it for the first six or seven months ; 
ami, certainly, the practice of feeding the infant during the night, so 
as to avoid trouble and disturbance to the mother, which has become 
too common of late, is one to which — save under exceptional circum- 
stances — we should give no countenance. A partial failure in the 
quantity or quality of the milk may, no doubt, occur at a period very 
much earlier than that to which we refer; so that it may be absolutely 
necessary, even at the second or third month, partially to feed, while 
nursing is simultaneously going on. It is, in all cases, advisable to 
accustom the infant to other food before the breast-milk is withdrawn ; 
otherwise, the process of weaning is much more troublesome, and is 
more likely to be productive of unsatisfactory results. When this is 
done, and when the proper time arrives, the quantity of milk should 
be gradually and steadily diminished, and the proportion of other 
nutriment correspondingly increased, until the latter alone remains. 
Seldom, however, is this effectual without more or less of trouble, 
arising from the restlessness which the deprivation of the milk excites 
in the child ; but, if the weaning process has not been too abrupt, the 
screaming fits and other evidence of discomfort will not last beyond a 
couple of days. And, as regards the mother, any discomfort which 



XXXIX.] DENTITION. 639 

she may experience may be easily kept within moderate bounds by 
saline laxatives, abstinence from fluids, and the application of bella- 
donna or cooling lotions to the breast, until the gland ceases to discharge 
its function. 

The general health of the child is the point which, above all others, 
is of importance in its bearing on the period to be selected for weaning. 
It is proper, therefore, to await the subsidence of any febrile attack, or 
even of an ordinary catarrh, or some other trifling ailment, before 
weaning the child ; and it is, we may say, the universal practice to 
regulate the process, in some measure, by the progress of dentition, 
which is, as we shall see presently, almost invariably marked by stages, 
these being separated by intervals, during which such constitutional 
disturbance as may attend the eruption of the teeth completely disap- 
pears. It is well, therefore, to select the latter periods as those at 
which constitutional irritation is less likely to be engendered. There 
is, as we may well suppose, the greatest difference in the ease with 
which children are weaned — the deprivation causing, in one case, 
scarcely a gesture indicating uneasiness or discomfort, and, in another, 
a degree of fretfulness, and even of constitutional disturbance, which 
seems quite out of proportion to the cause. This depends, no doubt, 
upon the temperament, or possibly, upon constitutional causes ; but 
there is every reason to believe that the idea, which has so long obtained, 
in regard to the bearing which the progress of dentition should have on 
the question of weaning, is well founded, and ought, in all cases, to be 
admitted, as affording indications of no small importance. But to 
attempt to fix absolutely the period of weaning, as applicable to all 
cases, is as absurd in theory as it would be found to be unsatisfactory 
in practice, were it for no other reason than the well-known irregularity 
which attends dentition. In the case of a perfectly healthy infant, and 
an average result in the eruption of the teeth, we may, however, assume 
that ten months is a proper period for weaning, as at this time there is 
usually a pause in the process of dentition, subsequent to the appear- 
ance of the eight incisors. 

Dentition. — Among the many reasons which indicate the necessity 
for a careful alimentation of the child during the early months of its 
existence, there is perhaps none of greater importance than that the 
system may be prepared for the contingencies which so often attend the 
eruption of the teeth. From imperceptible constitutional disturbance, 
to derangement of all the functions, and convulsions at the cutting of 
every tooth — which may be held as indicating the extremes — cases 
offer themselves presenting every conceivable variety of symptom in- 
termediate between the two. There are few more perfect illustrations 
of the delicate sympathy which exists between functional disturbance 
and distal irritation, than are afforded by watching the progress of the 
first dentition. As a rule, indeed, the symptoms are merely those of 
local irritation ; but in a large proportion of all cases, the sympathy 
referred to is evidenced by more or less of gastro-intestinal derange- 
ment, while, in a considerable number of instances, a reflex irritation 
is manifested in symptoms which indicate, more or less clearly, a 
disturbance of the nervous centres. 



640 THE NEWLY BORN CHILD. [CHAP. 

Although, as a general rule, the development of the milk teeth within 
the jaw involves neither local nor constitutional disturbance, and it is 
only as they are about to penetrate the gum that the symptoms to 
which we have alluded first manifest themselves, the influence of the 
process is sometimes exhibited a considerable time before the teeth 
upon which the phenomena depend make their appearance. So long 
as no tumefaction, or other morbid condition of the gum, is observable, 
our treatment can only be expectant, or, at least, directed to the func- 
tions which are disturbed ; but this is clearly one of the conditions to 
which we have already referred as indicating the necessity of caution 
in the matter of weaning — for there can be little doubt that, in such 
cases, a change, and especially a sudden change, in the nature of the 
food, is very likely to be followed by an aggravation in the general 
symptoms. Such a state of matters is, in fact, sufficient warrant for 
protracting the period of nursing until more favorable conditions 
manifest themselves, which w r ill generally be the case on the eruption 
of the first teeth. 

Although the process is subject to many irregularities, the teeth gen- 
erally make their appearance in a certain order, as is represented in the 
following formula, where the figures indicate the month at which, in 
mature and healthy children, we may expect the various teeth, the den- 
tition usually commencing with the incisors of the lower jaw : 



Molars. Canine. 


Incisors. 


Canine. 


Molars. 


24—12 


18 


9—7—7—9 


18 


12—24 



From this it appears that the milk teeth — which are twenty in num- 
ber — come through the gums in the following order. It is, of course, 
understood that an infant may be born with teeth, or may not have a 
tooth until several months later than is indicated by the formula, and 
in either case without -a single special symptom. On an average, then, 
the central incisors make their appearance in the course of the seventh 
month, and are followed, about the ninth, by the lateral incisors. After 
this, which is the time generally selected for weaning the child, there is 
a pause of something like three months. At the end of these three 
months, the first molars come to the surface; and, at intervals of six 
months, the canines and second molars respectively, — so that the denti- 
tion is usually completed about the end of the second year. If the 
delicacy of the child on the one hand, or premature or irregular erup- 
tion of the groups of the teeth on the other, should disturb our calcula- 
tions, it may be necessary to modify the ordinary routine procedure; 
and, in any case, the symptoms of irritation, local or general, to which 
reference has been made, and which indicate the approaching eruption 
of a tooth or group of teeth, should be held as warranting us in post- 
poning the period for weaning. 

A very limited experience in the treatment of the diseases of infancy is 
sufficient to show that the eruption of the deciduous teeth is intimately 
connected with many of the most important of these. It has, on this 
account, been admitted from time immemorial that the management of 



XXXIX.] DENTITION. 641 

children during teething, is a point which often involves both responsi- 
bility and anxiety. It is, however, a matter which can admit of no 
doubt that a knowledge of this familiar fact leads in no small number 
of cases to illogical inferences and slovenly practice. Nothing can well 
be imagined more irrational than to suppose that all the ailments which 
may affect the child during the period of dentition, depend upon local 
irritation, due to the impending eruption of the teeth ; and it is scarcely 
less absurd to conclude that all irritation is to be relieved by the pro- 
miscuous use of the gum lancet. On the latter point, West well ob- 
serves that — "such a proceeding is nothing better than a piece of bar- 
barous empiricism, which causes the infant much pain, and is useless or 
mischievous in a dozen instances, for one in which it affords relief." 

So long as the process of teething is going on quite naturally, or is 
only accompanied with restlessness or slight fever, the less we interfere 
the better. The progress of the tooth towards the surface is necessarily 
slow, but the manner in which the tissues of the gum which cover it are 
gradually attenuated, so as to admit of its final emergence, form no ex- 
ception to the generally admirable manner in which nature discharges 
her manifold functions in the animal economy. And yet it is too much 
the fashion in many quarters to have recourse to the lancet, in a very 
large proportion of cases, its use being supposed to be indicated by any, 
even the most trivial, of the ailments of dentition. In certain cases it 
is admitted that the lancet is the proper and only treatment; but, the 
more carefully we watch the natural process, the more cautious do we 
become in resolving upon lancing the gums of an infant. The condi- 
tions which may be admitted as warranting the operation are mainly 
these: 1st. When the child is suffering, and the tooth is so nearly 
through that we are sure that cutting down upon it will at once relieve 
the tension, and permit of the passage of the tooth. 2d. When the 
gums are swollen, hot, and tender, and obviously more vascular than 
usual, but in this case we operate, not with the view of bringing the 
tooth through, but to give relief to local symptoms, upon which con- 
stitutional disturbance may be supposed to depend; and 3d. The 
occurrence of convulsions during one of the periods of active dentition 
is generally, and with perfect propriety, looked upon as justifying us in 
using the lancet, even although the state of the gum may not seem to 
warrant the operation. This we do, less from a conviction that the 
procedure is likely to be efficacious, than in the hope that it may prove 
so. When a tumid state of the gum is associated with aphthae, or with 
that severe variety of inflammation of the gum to which in infants the 
name of Odontitis has been given, the use of the lancet, far from being 
beneficial, only makes matters worse. And where, in the case of tense 
and swollen gums, it is employed, not for the purposes of scarification 
but in the expectation of bringing the tooth through, there is some 
reason to fear — and, indeed, this is a point which is very generally be- 
lieved — that an incision of this kind results in a cicatrix, ultimately 
rendering the passage of the tooth through the gum more difficult than 
if we had left it untouched. 

The mode of cutting the gum varies according to the nature of the 
tooth over which we are operating. In the case of the incisors, the in- 

41 



64:2 PHLEGMASIA DOLENS. [CHAP. 

cision should be longitudinal, and directly along the cutting edge of 
the tooth. As regards the molars, again, it is usual to make a crucial 
incision. While we are inclined to think that the idea of a cicatrix in 
the gum proving a serious obstacle has been in some degree exaggerated, 
we think that it is well to avoid, if this be practicable, the possibility of 
any such result. This may be done in a very simple way by so operating, 
when we cut or scarify the gums with the mere object of depletion, as 
to avoid that portion of the surface through which the tooth must ulti- 
mately pass. We have generally found that scarification practiced, not 
over the alveolar ridge, but near the base of that portion of the gum 
which is chiefly affected, has a perfectly satisfactory effect, and besides 
this will also be found in most cases to be attended with a more consid- 
erable flow of blood than when we proceed in the usual way. It often 
happens that the effect of scarification of the gnms, although marked, 
is but temporary, and, on that account, it is frequently necessary to 
repeat the operation again and again, to subdue symptoms which are 
exceedingly apt to recur. 

In the treatment of Odontitis, the lancet should be scrupulously 
avoided, as there is here a tendency to the formation of troublesome 
ulceration at the site of any incision or scarification which may be prac- 
ticed. Our attention should, in such cases, be directed to the state of 
the digestive functions ; and, by a careful regulation of the diet and 
otherwise, — while the local affection is to be met by the application to 
the affected surface of a solution of borax, with or without the chlorate 
of potash, — the symptoms will generally in some degree be controlled. 
The latter drug may also be given internally, in the manner suggested 
by Dr. Hunt, in doses of two grains every four hours. 



CHAPTER XL. 

PHLEGMASIA DOLENS. 



the puerperal state in its relation to disease — phlegmasia dolens : 
nomenclature — causes : after labor and when unconnected with 
delivery — symptoms: premonitory signs: pain: white swelling: 
tension: heat: constitutional symptoms: the limb pits on pressure 
during convalescence: loss of power in the limb — morbid anatomy: 
character of the effused fluid: plugging of the veins: state of 
the lymphatics — pathology: milk-leg: angeioleucitis : crural phle- 
bitis : experiments of m'kenzie and h. lee: views of tilbury fox: 
review of the pathology of the subject — treatment: is bloodlet- 
ting justifiable? blisters: bandaging: is contagion possible? gen- 
eral treatment to be directed as a rule to a condition of debility : 
tonic regimen : antiseptic remedies — causes of protracted convales- 
CENCE. 

Passing now to the consideration of what are essentially diseases 
of the puerperal state, we observe that, apart from such affections 



XL.] PHLEGMASIA DOLENS. 643 

as are assumed to belong to the condition referred to, there is ample 
evidence of a peculiar constitutional sensitiveness, one effect of which 
is to increase the gravity of symptoms arising from what, under other 
circumstances, we would call quite ordinary diseases. There is, in fact, 
no disease to which a recently delivered woman is not as liable as 
others ; but in her case there is this special danger, that what we would 
call but a trivial ailment may, in consequence of the special conditions 
under which she is placed, be attended with symptoms of serious and 
alarming import. An ordinary catarrh, for example, may so disturb 
that repose of the functions, which seems to be a prominent character- 
istic of the puerperal state, that an amount of constitutional disturb- 
ance is produced out of all proportion to the essential nature of the 
disorder. A state which is naturally one of calm quiescence is changed 
to a condition in which a turbulent circulation, arrested secretions, and 
violent fever, give no small cause for anxiety ; and it is on this ac- 
count that we so carefully guard against the occurrence of such influ- 
ences as may change the case at once from a favorable into an unfavor- 
able category. All ordinary diseases, then, which are accompanied with 
what are called febrile symptoms, are looked upon with considerable 
apprehension, as they are apt to be accompanied, in the special cases in 
question, with a train of supernumerary symptoms which are held as 
characteristic of the puerperal state. 

It is, perhaps, in a sense, not too much to assume, that what are 
called the diseases of the puerperal state are merely more marked illus- 
trations of the condition to which we refer. The peritonitis, the 
metritis, the mania of a puerperal patient, are thus nothing more than 
familiar diseases modified by special conditions, one of which is what 
we have ventured to call, for lack of a better name, a peculiar consti- 
tutional sensitiveness. We are amply warranted, however, as the 
sequel will show, in considering each of these affections with reference 
to the period succeeding delivery ; and we shall find that, not only are 
the symptoms modified, but they are so to such an extent as to require, 
in many cases, a treatment quite different from that which is supposed 
to be applicable to the disease in its ordinary form. 

Phlegmasia Dolens, or Phlegmasia Alba Dolens — the disorder which 
forms the subject of this chapter — forms no exception to the rule just 
stated. It is, indeed, more strictly a disease of the puerperal state 
than many of the affections which we shall have to consider, inasmuch 
as it is seldom observed save as associated with recent delivery. That 
the puerperal state is not, however, essential to its manifestation is 
universally admitted, as it has sometimes been met with in women 
who have never been pregnant, and even in persons of the opposite 
sex. Few diseases have had a greater variety of designations applied 
to it than this : anasarca serosa, phlegmasia lactea, oedema lacteum, white 
leg, and crural phlebitis, being but a few of the many appellations under 
which it has been described, a study of which, indeed, is not unin- 
structive, as it almost gives an epitome of the various pathological 
theories which have been successively advanced to account for the 
somewhat peculiar phenomena of the disease. Excluding the very few 
cases in which it, or a precisely similar condition, has been observed to 



6±4 PHLEGMASIA DOLENS. [CHAP. 

attack the arm, phlegmasia clolens consists in a white painful swelling 
of the leg. Although, as we have said, it is not necessarily associated 
with the puerperal state, it is almost always observed in women who 
have been recently confined, the period of its occurrence varying from 
the fifth to the thirtieth day, and, in very exceptional cases, at an earlier 
or later date than the extremes mentioned. It is more common in 
pluriparae than in primiparse, and is more likely to occur in women 
who are of a feeble and delicate constitution than in those who are 
robust. In a very considerable number of cases, it has followed the 
various accidents and complications of delivery, and has even been 
noticed to occur more frequently after removal of a retained placenta. 
All English writers on the subject agree in asserting that it usually 
attacks the left in preference to the right leg, which Mr. White of 
Manchester seemed to think was due to the fact of women in this 
country habitually lying on the left side during labor; while Dr. 
Ramsbothani supposed that it "may possibly, in some inexplicable 
manner, be dependent on the different distribution of the right and left 
spermatic vein — the right terminating direct in the vena cava, the left 
in the renal." 

In no class of cases has it been so frequently observed as in women 
whose strength has been reduced to a low ebb by haemorrhage either 
during or after labor; and this, no doubt, accounts for the observation 
made by Merriman that it is relatively of common occurrence after 
placenta praevia. Women who have once suffered from phlegmasia 
dolens are by no means so liable to it in subsequent pregnancies as we 
might perhaps be disposed to anticipate; and it has generally been 
observed that when it does so recur the subsequent attacks are much 
less violent. Mr. White says that he never knew it happen to a woman 
more than once ; but this does not tally with the experience of most 
modern practitioners. One very troublesome and annoying peculiarity 
of this affection, is the tendency, exhibited unfortunately in a consider- 
able proportion of cases, which the disease has, after having partially 
run its course in one leg, to be transferred to the other, and there pass 
through the same tedious stages, still further reducing the strength of 
the woman, and postponing the period of her convalescence — it may be 
by several months. 

It may be interesting here to mention the circumstances under which 
phlegmasia dolens has been observed when unconnected with recent 
delivery. Puzos and, since his time, many modern writers have re- 
corded cases in which all the usual phenomena have been manifested 
in the course of pregnancy. In a more considerable number of in- 
stances, it has been observed as occurring after abortion, particularly 
ill; cases in which the placenta or any other portion of the ovum has 
been left behind. It has also been found to occur after the removal of 
polypi, the enucleation of fibrous tumors, and the operation of lithot- 
omy. In another class of cases, to adopt the classification of Dr. 
Tilbury Fox, it may be met with as part of a general disease. Under 
this head he includes those instances in which it has been developed as 
one of the distressing phenomena of puerperal fever ; and, occasionally, 
in cases of ordinary continued fever, a similar complication has been 



XL.] SYMPTOMS. 645 

found to arise. With this variety are ranged three cases in which it 
was observed to coexist with dysentery, erysipelas, phthisis, and what 
Dr. Humphry described as a " preternatural coagulability of the fibrin 
of the blood." A considerable number of instances have been recorded 
in which the disease has been associated with malignant growths, not 
in the pelvic region merely, which we could more readily understand, 
but as affecting distant organs, such as the stomach or the mammary 
gland. In a third class of cases, still observing the classification of 
Dr. Fox, phlegmasia dolens is met with as complicating other local dis- 
eases ; and under this head are ranged, and all on sufficient authority, 
examples of iliac abscess, suppressed menstruation, haemorrhoids, 
hepatic disease, and dislocation of the shoulder. These exceptional 
cases have, as we shall find, an obvious and important bearing on the 
hitherto obscure pathology of the affection. 

Symptoms. — As in most other diseases, the violence and typical dis- 
tinctness of the symptoms of phlegmasia dolens vary considerably; and 
in some cases they are so feebly marked, that we have difficulty in 
determining whether the case should be classified under this head or 
should be considered as a simple case of oedema. In an ordinary case, 
the symptoms may either come on suddenly, when they are often ush- 
ered in by a rigor of some severity, or they may manifest themselves 
more insidiously, when certain premonitory signs are frequently noticed. 
These are, generally, — in the puerperal variety, to which we shall in 
future exclusively refer, — a feeling of weight and discomfort in the 
hypogaster, extending round the brim of the pelvis, which is soon re- 
placed by actual pain, accompanied with more or less of constitutional 
disturbance. The pain is commonly referred more particularly to the 
inguinal region on the side which is about to become the seat of the 
disorder. We have more than once noticed that pain is complained of 
in the region of the hip-joint; but as this is not mentioned by other 
writers on the subject, we infer that the occurrence is exceptional. Dr. 
Denman describes, as a premonitory symptom, that "before the appear- 
ance of any swelling or sense of pain in the limb about to be affected, 
women become very irritable, with a sense of great weakness, and 
grievously oppressed in their spirits, without any apparently sufficient 
reason; complaining only of transient pains in the region of the uterus, 
and from these the approach of the disease has frequently been fore- 
told." The pain commencing, as has been described, in the inguinal or 
pelvic region, extends downwards, and as the various districts of the 
thigh and leg become successively invaded by it, the swelling of the 
limb steadily advances in the same direction, until, at the height of 
the disease, the whole limb presents the white, glazed, and sometimes 
enormously swollen condition which is so eminently characteristic. This 
is further accompanied by a complete loss of power, the patient being 
quite unable to move the limb, or indeed to change her position in bed 
without assistance. The tissues are tense and elastic, but although they 
yield before the finger, they do not pit on pressure after the swelling 
has assumed its characteristic appearance. The temperature of the limb 
is usually increased. 

Notwithstanding the great swelling of the limb, the veins can gen- 



646 PHLEGMASIA BOLENS. [CHAP. 

erally be distinctly felt, hard and rolling under the ringer like a thick 
cord. This is more particularly the case in regard to the femoral vein, 
which may often be traced from the groin downwards, although the 
pressure gives rise to considerable pain. The swelling in some cases 
extends to the hip and vulva. The glands of the groin participate in 
the irritation, and sometimes become affected with well-marked inflam- 
matory action, although they very rarely suppurate. The action obvi- 
ously extends to the lymphatics, and sometimes the only appearance 
which varies the surface of the white limb is a faint red streak here and 
there, indicating the situation of the affected vessels. A similar appear- 
ance, which in this case is more diffused, has also been observed over 
the course of the venous trunks. It was first remarked by Dr. Stokes, — 
an observation which has been corroborated by Dr. Churchill, — that 
the amount of the swelling is no proof of the severity of the disease; 
but that, on the contrary, "the severity of the constitutional symptoms 
is often inversely as the swelling of the limb." 

In a certain number of eases, the symptoms run a somewhat different 
course. Obviously, in the instances referred to, the disease does not 
originate in the pelvis, and is ushered in by no such preliminary pelvic 
symptoms as have been described above. "Sometimes," says Burns, 
"there is no uneasiness in the belly, and the first symptom is sudden 
pain in the calf of the leg. Within twenty-four hours after the pain is 
felt, the limb swells and becomes tense; it is hot but not red — it is 
rather pale, and somewhat shining." It is a matter of considerable 
importance that the peculiarities of this variety, which is by no means 
uncommon, should be borne in mind; for otherwise the idea of "crural 
phlebitis," which is very commonly supposed to express the pathology 
of the disease, might altogether divert our attention from symptoms 
which are nevertheless identical in all important particulars with those 
which are truly characteristic of phlegmasia dolens, the only difference 
being that in the cases which we are here considering, the disease 
begins below and thence extends upwards. 

The constitutional symptoms are just such as one might anticipate 
from a local affection of such importance. The lochia! and lacteal 
secretions are either arrested or modified, and in the case of the former, 
the discharge sometimes becomes offensive. The degree of the fever is 
indicated by the frequency of the pulse, which is seldom under 120. 
The complete loss of appetite, the furred tongue, and the state of the 
evacuations, all show how much the gastro-intestinal functions are 
disturbed. The patient is restless, sleepless, and complains much of 
thirst. 

After a time, which varies much in different cases, all the symptoms 
undergo an improvement. The fall of the pulse, and the subsidence 
generally of the constitutional symptoms, are accompanied both by 
relief of pain and a diminution in the swelling of the leg. A remark- 
able change now takes place in the character of the swelling, as it is no 
longer elastic and resistant, but pits on pressure like ordinary oedema ; 
and this change is sometimes observable before there is any very marked 
difference in the size of the leg. The loss of power in the limb, most 
marked in cases where the swelling has commenced at the groin, is often 



XL.] PATHOLOGY. 647 

very persistent, and is one of the last symptoms to yield. We may 
expect, therefore, occasionally to meet with cases in which, in the 
absence of all evidence of constitutional disturbance and apparently of 
local change, this paralyzed condition of the leg remains for months 
and even for years. In some cases of exceptionally long continuance 
of immobility, there remains a permanently thickened condition of the 
tissues, which may somewhat increase the circumference of the limb. 
In most cases, the ordinary sensibility of the leg is affected for a con- 
siderable time, and the patients often complain of what Dr. Churchill 
graphically describes as a wooden feel, which may persist in a degree 
for a long period. A varicose condition of the veins has been sometimes 
observed after phlegmasia dolens, which has been supposed by some to 
be due to a special morbid condition. 

But, while the great majority of cases thus end in resolution, and 
ultimately in satisfactory although possibly tardy convalescence, it is 
not always so. For, in a few, suppuration occurs, in the limb itself, 
in the inguinal glands, or within the pelvis, in which latter case it may 
be difficult to say which is the primary and which the secondary dis- 
order. As the result of such suppuration, and, in some very rare 
instances, of gangrene, the exhaustion is so great that the patient suc- 
cumbs; but so uncommon is such an event that the opportunities which 
have been afforded for the examination of the white leg after death are 
extremely rare. Let us see, however, what are the facts which morbid 
anatomy has disclosed. 

"On opening the limb/' says Churchill, "it is found to be distended 
with serum, effused into the cellular membrane." This assertion is no 
doubt correct, but it is incomplete, and, being so, is apt to lead to an 
erroneous assumption. The words quoted will serve equally well for 
the description of what is observed when we cut into a part distended 
by ordinary oedema ; but the symptoms already detailed show one thing 
at least very clearly, that phlegmasia dolens is something essentially 
different from oedema. It has been found, moreover, that the fluid 
which exudes in the latter condition is watery in its nature; but care- 
fully observed facts have shown that the limb, and especially the fibro- 
cellular and cutaneous tissues, are distended in phlegmasia dolens, with 
a peculiar serosity which is more or less coagulable. Again, thrombus 
or plugging of the venous trunks of the limb, usually in the neigh- 
borhood of the groin, has been so constantly observed that it may be 
assumed as a phenomenon essential to the disease. This may exist 
with or without inflammation of the coats of the vessels. And, fur- 
ther, the great majority of observers have noted that the lymphatics are 
also affected, their main trunks and more important glands often yield- 
ing evidence of inflammatory action, which in the latter situation has 
occasionally, gone on to suppuration. 

Pathology. — The symptoms, morbid appearances, and even the va- 
rieties in nomenclature, all strongly point to one conclusion, — that the 
pathology of this disease has given rise to many differences of opinion, 
is in itself peculiar and perplexing, and remains, even at the present 
time, still somewhat obscure. It was at one time generally believed 
that the "white leg" was due to the presence of milk in the limb, and 



648 PHLEGMASIA DOLENS. [CHAP. 

the idea was so far favored by the fact, that in most cases the lacteal 
secretion disappears. It is, however, somewhat surprising to find 
Puzos and Levret giving their countenance to an idea so absurd ; for, 
although pathology in their days was still in its infancy, their assump- 
tion was far less advanced than the views of Mauriceau, who held, at 
a period seventy years earlier, an opinion which, indeed, comes pretty 
near some quite modern doctrines, when he describes the accident as 
one " which often succeeds pain in the ischiadic region, and is caused 
by a reflux — which takes place on those parts — of the humors which 
ought to be evacuated by the lochia." The believers in this theory of 
a metastasis of the milk recommended that the child should be kept 
constantly to the breast. 

Towards the end of the last century, the subject attracted consider- 
able attention in this country. Mr. White, of Manchester, then ad- 
vanced the theory that the disease depended on obstruction, or on some 
other morbid condition, of the lymphatic vessels and glands of the 
affected part; and subsequent writers suggested rupture of the lym- 
phatic vessels, or an inflammatory condition of the same parts, as the 
morbid lesion to which the familiar phenomena of the disease were, 
at least primarily, to be attributed. The opinion adopted by Dr. Hull 
was, that phlegmasia dolens consists "in an inflammation of the mus- 
cles, cellular membrane, and inferior surface of the cutis, extending, in 
some cases, perhaps, to the large bloodvessels, nerves, lymphatics, and 
glands." This, which was sarcastically called by Davis "Dr. Hull's 
capacious theory," indicates a belief that the disease is due to inflamma- 
tory action, but it otherwise throws no light upon the subject. Up to 
this time, no suspicion seems to have been entertained as to the part 
which the veins take in the production of the symptoms. The priority 
of publication on this subject is due to M. Bouillard, who, about the 
end of 1822, related several cases and dissections, — which were shortly 
afterwards published in the Archives Generates, — in which the crural 
vein was obliterated, and in regard to which he expressed a belief that 
the peculiar symptoms of this disease were due to obstruction of the 
venous trunks. Several years before this, the attention of Dr. Davis 
had been particularly attracted to this subject, in consequence of the 
death of a patient of his from phlegmasia dolens, but his essay was 
not published till some months after the date of M. Bouillard's com- 
munication. 

In the case in question, a very careful dissection was made by Dr. 
Davis, assisted by Mr. Lawrence, in the course of which it was demon- 
strated that " the femoral veins, from the ham upwards, the external 
iliac, and the common iliac vein as far as the junction of the latter with 
the corresponding trunk of the right side, were distended, and firmly 
plugged with what appeared a coagulum of blood. The femoral por- 
tion of the vein, slightly thickened in its coats, and of a deep-red color, 
was filled with a firm bloody coagulum, adhering to the sides of the 
tube. The trunk of the profunda was distended in the same way as 
that of the femoral vein ; but the saphena and its branches were empty 
and healthy." Ultimately, Dr. Davis advanced the theory that phleg- 



XL.] PATHOLOGY. 649 

masia dolens is essentially Crural Phlebitis, and under this name, as a 
synonym, the affection is still described by most English writers. 

Although for a time the authority of Dr. Davis, supported by the 
corroborative testimony of Dr. Robert Lee and others, seems to have 
checked further inquiry, and to have resulted in a general belief, that 
what had been for so long a physiological problem was at last solved, 
many of the best pathologists were still dissatisfied with the phlebitic 
theory, and we believe with good reason. Virchow was one of the first to 
point out — what has since received ample corroboration — that, in phleg- 
masia dolens, inflammatory changes in the vessels may be altogether 
absent. In other words, thrombus is not necessarily preceded, although 
it may be followed, by inflammation of the coats of the vein where the 
obstruction has taken place. In this country, Dr. McKenzie took a 
prominent part in opposition to the views which were generally admit- 
ted. In the course of a very painstaking investigation of the subject, 
conducted, to a great extent, in the form of experiments on the lower 
animals, the inferences which he ultimately drew from his labors were 
as follows : 1. That inflammation of neither the iliac nor femoral veins 
would account for, or give rise to, phlegmasia dolens ; 2. That the ex- 
tensive obstruction of the veins met with in this disease is not producible 
by merely local causes, such as injury or inflammation of these vessels ; 
3. That irritation of the lining membrane of the veins, independ- 
ently of such local injury or inflammation, will only give rise to ob- 
struction of these vessels, to an extent commensurate with that of the 
irritation which may have been excited within them ; 4. That exten- 
sive irritation of the lining membrane of veins, giving rise to obstruc- 
tion and all the phenomena of phlebitis, may be excited by the 
presence of various unhealthy matters in the blood circulating with this 
fluid, and determined upon particular portions of the venous system ; 
5. That the origin of the disease is therefore to be sought for rather in 
a vitiation of the circulating fluid than in any local injury, imflamma- 
tion, or disease of the veins. 

Mr. H. Lee also performed a series of experiments conducted on a 
somewhat similar principle. His observations were meant to show, 
and, in point of fact, did clearly show, that it is by no means an easy 
matter to excite inflammatory action in the lining membrane of veins, 
even although irritant or septic substances be introduced into the veins 
and brought directly into contact with their lining membrane. These 
results are in perfect harmony with those which, quite independently, 
were obtained by Dr. McKenzie. Experiments were also devised by 
the latter with the view of determining the effect of irritation on the 
external coats of the vessels; and, although he injured and irritated 
their coats in various ways so as to excite localized inflammatory 
action, he found that such inflammation showed little tendency to 
spread, and that the lining membrane remained free from any effect 
arising from the irritation applied to the external parts of the vessel. 
Dr. McKenzie quite admits that coagulation of the blood contained in 
a vein is one of the phenomena of true phlebitis ; but he insists, and, 
we think, proves, that changes in the blood, due to septic action, may 
produce a thrombus with equal certainty. The effect of an admixture 



650 PHLEGMASIA DOLENS. [CHAP. 

of pus in precipitating the fibrin is clearly demonstrated in the follow- 
ing experiment, which is one of those performed by Mr. H. Lee : 
"Some blood was drawn from a healthy horse, and poured into three 
vessels capable of containing three ounces each. The blood in the 
first vessel was allowed to remain as a standard of comparison. To 
that in the second vessel was added some viscid matter from an indolent 
tumor in the horse's neck ; to that in the third, some pus from a 
chronic abscess. The contents of the third vessel (blood and pus) 
began to coagulate in three minutes ; the mass was firm in four. In 
eight minutes the contents of the first and second vessels had become 
firm." 

Dr. Tilbury Fox, in two very able papers communicated to the 
Obstetrical Society of London in 1861, and published in their Trans- 
actions for that year, enters very fully into the subject, and strongly 
opposes the view that phlebitis is an essential phenomena of phlegmasia 
dolens. His leading idea is, that the cause of the peculiar phenomenon 
of white leg "is an impediment to the return of blood and lymph from 
the affected part •" and he goes on further to observe, "that the causes 
of such impediment may be, so far as regards the vessels, extrinsic and 
intrinsic" The extrinsic causes comprise all cases of pressure on the 
vessels from tumors, abscess, etc. The intrinsic causes again are all 
assumed to produce coagulation, and the more important of these are: 
1. Phlebitis, septic or non-septic; 2. Introduction of morbid matter 
into the vein, producing simple thrombus, but not phlebitis; 3. Pre- 
ternatural coagulability of the fibrin of the blood, as assumed, and, in 
a manner, proved by Drs. Humphry and Graily Hewitt. While not 
denying the possibility of crural phlebitis being associated with, or 
even preceding the phenomena of phlegmasia dolens, Dr. Fox argues 
with much force and ability in favor of the conclusion that a septic 
action proceeding from the denuded inner surface of the uterus is the 
most probable cause of the disease. With reference to this he writes 
as follows : 

" It can in no wise be denied that the parturient woman is a subject 
apt for the occurrence of thrombus ; there is hyperinosis, the uterus 
offers a denuded stop, its veins are thin, osmosis is easy, the lymphatic 
act and circulation are active in removing the disintegrating uterus in 
conjunction with the veins, etc. These constitute an analogous con- 
dition to that stage in which phlegmasia dolens is wont to occur else- 
where — I mean the ulcerative stage and kind of disease, e.g., dysentery, 
cancer, phthisis — so much so that we should not expect it to occur when 
wound is absent, except from extrinsic pressure. This close relation 
of wound in the one case — phlegmasia dolens — and the absence of it 
in the other — oedema — is a contrasting difference in the pathology of 
the two states ; in other words, where wound is, the lymphatics are 
involved. Now for the culminating point, — the cause of the rapid 
absorption. I have been particularly struck, in the cases that have 
come under my notice from the outset, by the occurrence of notable 
haemorrhage, or profuse discharge of other kind ; and I find, from 
close inquiry, that the reminiscence of the practice of others, well able 
and qualified to give an estimation of the point, affords the like result. 



XL.] PATHOLOGY. . 651 

I have been desirous for some time to ascertain if there be any relation 
between the two phenomena, — discharge and phlegmasia dolens. My 
belief is, that the cases which cannot be accounted for by the existence 
of phlebitis, or pressure, are due to simple coagulation, the result of 
tolerably rapid absorption of morbid fluid ; this excess of absorption, 
over and above what is natural, being induced by the occurrence of 
notable sudden discharge — the latter being the culminating point in 
the causation. We do find present facility for rapid absorption, wound, 
and morbid fluid, in the cases in which phlegmasia dolens, of the type 
under discussion, occurs. Of course, this is at issue with Dr. Humphry, 
who, in his recent pamphlet, says that there certainly seems no reason 
to attribute the affection to an introduction of pus, or other morbid 
fluid, into the circulation/' 1 

Dr. Fox sums up his conclusions, with reference to the disease under 
consideration, as follows : " Prop. I. In phlegmasia dolens both veins 
and lymphatics are obstructed. Prop. II. The obstruction may be due 
simply to extrinsic pressure. Prop. III. Or to inflammatory changes 
in the coats of the vessels, leading to coagulation. (This depends upon 
virus action.) Except during epidemics of puerperal fever, this is not 
so common as supposed. Prop. IV. It is pretty well admitted that 
rapid ingress of abnormal fluid, suddenly, and in large amount, will 
cause instantaneous coagulation of the blood ; and it is also admitted 
that large drains from the system are followed by rapid and compen- 
sating absorption. There is good reason for believing that these con- 
ditions are fulfilled, in a perfect and ample degree, in conjunction with 
the presence of wound — facilitating absorption — in a great many cases 
prior to the occurrence of phlegmasia dolens, and that the latter is 
frequently thus evolved. Prop. V. These different modes of evolution 
may be more or less conjoined." 

On a review of the whole subject, and setting aside such of the older 
theories as are clearly incompatible with the possibilities of modern 
pathology, we cannot but admit that phlegmasia dolens is still a matter 
in regard to which we have much to learn. That obstruction of the 
venous trunks, from whatever cause arising, is essential, we do not 
question ; but it is clear that this will not account for the phenomena 
which we observe, since the symptom which, above all ethers, is held 
to be indicative of an obstruction to the venous return — oedema, to 
wit — is, during the active stage of the disease, absent. Nor do we 
believe that the simple theory of phlebitis can be accepted as a solu- 
tion of the problem, in so far, at least, as this may be considered the 
proximate cause of the disease. No one can dispute that phlebitis 
causes coagulation of the blood contained in the affected vein. In those 
cases of phlegmasia dolens in which the affection has been associated 
with the more serious varieties of puerperal fever, clear evidence of 
inflammation of the coats of the veins has been observed ; and the 
theory referred to has received still further corroboration from the 
observation of Dr. Robert Lee, who traced such venous inflammation 

1 u Transactions of the Obstetrical Society of London." 1861. 



652 PHLEGMASIA D0LENS. [CHAP. 

to its most probable source, in the uterine branches of the hypogastric 
vein. 

But, on the other hand, it has been satisfactorily demonstrated, both 
by Dr. McKenzie and by Mr. H. Lee, that the veins, and especially 
their lining membrane, are singularly averse to taking on inflammatory 
action ; and it has also been shown, with almost equal certainty, that 
the deeper color of the membrane referred to is not a necessary indica- 
tion of inflammation, but is due rather to the action of the coloring 
matter and the contact of the clot. But, were we even to admit that 
phlebitis is an essential part of the disease now under discussion, there 
is no sufficient evidence that the one condition depends upon the other. 
If we study the description given by surgical pathologists of the affec- 
tion known as "fibrinous phlebitis," with which alone phlegmasia do- 
lens can fairly be compared, we find that, among the more important of 
the symptoms which are detailed, swelling of the limb below the affected 
part and oedema of the surrounding cellular tissues are among those 
which are most prominently put forward. In no single case, so far as 
we know, since M. Breschet first demonstrated and named the affection, 
has phlebitis been described as involving, in the case of a limb, the 
white, elastic, painful, and benumbed condition which is so diagnostic 
of the other disease. We do not hesitate, therefore, to reject the term 
"crural phlebitis" as synonymous with phlegmasia dolens. 

While giving every weight to the authority of such names as Denman, 
Caspar, and Dewees, we confess that the theory with which their names 
are associated is even less satisfactory than the other, for were we to 
admit that angeioleucitis may account for the appearance and character 
of the swelling, this affords no explanation whatever of the fact that the 
veins are plugged with clots. We may indeed be perfectly sure that to 
them the fact last mentioned was unknown; for had it been brought 
under their knowledge it could scarcely have failed to prove to them 
that, even if, as Denman said, "the glands and lymphatics of the limb 
were evidently the parts first and primarily affected," there was some- 
thing more than this necessary to account for the phenomena ordinarily 
observed in these cases. What has already been explained in reference 
to the symptoms of the disease, and the attendant morbid conditions, 
certainly proves that, in some cases at least, the vessels and glands 
of the lymphatic system are involved; but probably no one will now 
attempt to maintain that an inflammation of these structures will, if 
uncomplicated, account for the w 7 hite leg of the puerperal state. 

On the whole evidence, we are of opinion that the first crude theory 
of Maurieeau points significantly in the direction to which we may most 
confidently look for a solution of the difficulties which beset the subject. 
We do not of course mean that his quaint idea of a "reflux of humors" 
from the womb upon the limb was, in the sense which he attached to 
the expresssion, a pathological speculation w r hich modern experience 
could justify; but rather that, in thus pointing out a possible connec- 
tion between a local lesion and a septic action, starting as in other 
analogous cases from the wound, he indicated, in a striking manner, the 
direction in which we should seek for a solution of the problem. There 
is abundant evidence to prove that septic agents of various kinds may 



XL.] PATHOLOGY. 653 

cause coagulation of the blood. The experiments of Mr. H. Lee, 
already alluded to, showed that pus produced this effect. Dr. McKenzie 
ligatured the left femoral vein of a dog and injected half an ounce of a 
solution containing lactic acid. The animal died in half an hour, and 
on examination it was found that "the iliac veins on the left side from 
the femoral up to the cava, and a considerable extent of the cava, were 
obstructed by what appeared to be a firm coagulum; and on opening 
these vessels this was found to be closely adherent to their lining mem- 
brane." An exceedingly interesting case bearing on the same point is 
given by Dr. Tilbury Fox, of a lad, aged twelve years, who, being 
bitten in the thumb by an adder, presented next day "a perfect and 
complete specimen of phlegmasia dolens" in the affected limb, so that 
we may assume that coagulation had been at least one of the results of 
the poison which was introduced in the manner described. 

On the whole, therefore, we think that the preponderance of evidence 
is in favor of the idea that, in most cases of phlegmasia dolens, there 
is a precipitation of the fibrin by the action of some septic agent which 
has made its way into the blood, or has been developed in that medium. 
In this sense, Virchow's theory " that the first pathological condition is 
the formation of a clot in the vein," may be accepted as highly probable. 
Certainly this is more likely than that true phlebitis is essentially the 
proximate cause, although no one can dispute either that phlebitis may 
cause coagulation, or that inflammation of the vein-tissues may accom- 
pany the other and more essential phenomena of phlegmasia dolens. 
It may obviously, and with perfect propriety, be urged against this 
theory that a septic action having its origin in a wound cannot apply to 
those cases in which the symptoms of undoubted phlegmasia dolens 
manifest themselves unconnected with the pregnant state. But we 
cannot see that this must necessarily be admitted as a serious difficulty ; 
for, if the proximate cause of the disease is assumed to be a septic action 
proceeding in a great majority of cases from the recently denuded uterine 
surface, it is surely not too much to assume that, in exceptional cases, 
the septic action which leads to coagulation may proceed from intrinsic 
causes, or even from poison introduced in some other way from without, 
as in Dr. Tilbury Fox's case above alluded to. 

It is, however, impossible to avoid the conclusion that a septic action 
and the resulting coagulation cannot satisfactorily account for all the 
phenomena of the disease. All that is necessarily involved in such a 
hypothesis is mechanical obstruction in a venous trunk, from which we 
could only anticipate oedema as a direct result. To the development, 
therefore, of the white elastic swelling something more is required ; and 
this forces upon our notice the inquiry as to what are the auxiliary or 
supplementaiy conditions referred to. 

No modern writer on the subject ventures to advocate the theory, 
which at one time had the support of the most distinguished obstetri- 
cians of the age, that the seat of the disease is essentially in the absorbent 
or lymphatic system. The facts demonstrated with reference to the 
veins preclude such a belief. But it by no means follows that the 
absorbent system takes no share in the development of the symptoms 
alluded to. The red streaks occasionally observed over the course of 



654 PHLEGMASIA DOLENS. [CHAP. 

the larger lymphatic vessels, and the exceptional occurrence of inflam- 
mation and suppuration in the glands, prove quite clearly that they 
may be involved. But there are other considerations which seem to 
indicate something more than this, and that an affection of the lym- 
phatics is an essential, although, probably, a secondary part of a typical 
case of phlegmasia dolens. If we assume, as some of the most dis- 
tinguished of modern pathologists have done, that the lymphatic system 
affords the channel through which the fibrin is introduced into the 
blood, we can readily understand why an obstruction in the vessels of 
that system, whether inflammatory in its nature or purely mechanical, 
may cause many of the essential phenomena of the disease. Plugging 
of a venous trunk could but cause oedema ; but venous obstruction, 
plus an impediment to the circulation in the lymphatic system, may 
very readily be assumed to cause symptoms very like those which we 
have already described. " If there be any relation," says Dr. Fox, 
'■ between the lymphatic fibrin and the cellular tissue, it is easy to 
understand how obliteration of the lymphatics may give rise to the 
peculiar character of phlegmasia dolens, on account of the retention of 
the fibrinous material in the tissues — the cellular especially, which is 
so rich in lymphatics. . . . The cellular tissue itself seems to be hyper- 
trophied, the lymph also gelatinizing in its interstices." 

The marked loss of power in the affected limb, out of all proportion 
to the mere amount of swelling, and which is, as we have seen, fre- 
quently of long continuance, seems, at one time, to have led to the idea 
that the nerves were primarily involved ; and M. Duges has certainly 
shown that, in some cases at least, inflammation of the nerves and of 
their sheath occurs. It seems to us, however, that serious lesion of the 
nervous trunks is, even from a purely theoretical point of view, by no 
means necessary to the temporary paralysis so characteristic of the dis- 
ease. All, in fact, that is necessary to the arrestment of the nervine 
functions is pressure; and, in the condition to which the parts are 
reduced in the rapid development of a tense swelling, we may be sure 
that the nerves can scarcely escape such pressure as may produce the 
effect to which we refer. 

The confusion which has so long prevailed in regard to the pathology 
of phlegmasia dolens seems to have been due, in a considerable degree, 
to the obstinacy w T ith which pathological theories were pinned to affec- 
tions of the individual tissues or textures. No such theory can, as it 
seems to us, satisfactorily account for what, in these cases, we observe. 
It is, no doubt, of great interest to determine, if we can, what part or 
parts of the animal economy are primarily involved ; but we may be 
quite sure that, if we take up any exclusive theory, as to the disease 
being one of a single fluid or a single texture, we may pass into a field 
of speculation which is little likely to lead us to the truth. Doubtful 
though many points in regard to its pathology may be, we have no 
difficulty in refusing to admit of Crural Phlebitis, or Angeioleucitis, as 
terms which represent the true nature of phlegmasia dolens. Either 
of these conditions may, no doubt, exist; but if it be so, they are 
secondary rather than essential. Thrombus, or obstruction otherwise 
to the venous return is apparently essential ; and, in so far as the 



XL.] TREATMENT. 655 

absorbents are concerned, it is possible that Dr. Tilbury Fox is correct 
in assuming that a similar obstruction is produced in them. But, as 
regards the latter, no plugging of lymphatic trunks has ever, in so far 
as we are aware, been demonstrated. Nor do we believe that it has 
been established that the disease is inflammatory in its origin, nor even 
that the inflammatory process is, at any stage, an essential pathological 
condition. On the contrary, we think that we perceive in the narrative 
of post-mortem appearances in fatal cases, another, and a very obvious 
source of error. That morbid appearances indicating inflammatory 
action have been frequently observed after death, we can well believe ; 
but we must bear in mind that fatal cases are rare, and that, in ordinary 
cases, even when severe, there is rarely evidence, during life, of any 
such action. We demur, therefore, to the conclusion, that in the morbid 
phenomena of exceptionally severe cases, we have a demonstration of 
the essential features of what we have called an ordinary or typical 
case. Inflammation, in fact, we take to be, whether it is observable in 
the veins, the absorbents, or the contiguous tissues, an exceptional and 
essentially a secondary occurrence. 

Treatment. — The fact that phlegmasia dolens follows in so large a 
proportion of cases upon a condition of debility and exhaustion, usu- 
ally produced by haemorrhage, shows pretty clearly that the case is 
not one for an antiphlogistic regimen. This may be conceded even by 
those who believe most implicitly in the inflammatory nature of the dis- 
ease; and the opinion must necessarily gain strength if we assume that 
a septic action proceeding from or associated with constitutional ex- 
haustion, is an essential part of the disease. A belief in the inflamma- 
tory theory has not unnaturally led to a very general impression that 
bloodletting should usually be adopted. Few persons in the present 
day would probably think of general bloodletting, but it is commonly 
taught that leeches should be applied over the course of the affected 
vein ; and, indeed, the rules for treatment which are laid down by many 
writers on the subject are such as to convey the impression that leeches 
are applicable to all cases. Such an idea is, of course, at variance with 
the view which we have expressed as to the nature of the disease, and 
cannot, certainly, be admitted as a safe guide to judicious treatment. 
The cases, in fact, to which the application of leeches is advisable are 
those only in which there is evidence of a local inflammatory action, 
which may very readily be induced under such circumstances, either in 
the lymphatics or in some other of the tissues of the limb. But even a 
clear indication of true inflammation does not necessarily warrant de- 
pletion, for we must first — and this is the most important point of all 
— be sure that the aifection has not sprung from debilitating causes, for 
if it be so, to bleed is simply to encourage exhaustion, and to facilitate 
the absorption of septic materials. Bloodletting, then, we believe to 
be applicable to that comparatively rare class of cases only, in which 
inflammation exists in the absence of constitutional exhaustion. 

Considerable benefit appears to have been derived in many instances 
from the application of blisters to the leg. Some have gone so far as 
to say that in the treatment of this disease, blisters are to be regarded 
as specifics, but this is evidently a pardonable exaggeration. They may 



656 PHLEGMASIA DOLENS. [CHAP. 

be applied, as we believe, with a reasonable prospect of success, in cases 
where there is inflammation, and where the general condition of the 
patient prevents us from having recourse to bloodletting, and there is 
certainly one effect upon which we may count with some confidence, — 
that being a cessation, or at least an alleviation, of the pain which is so 
characteristic a feature of the more severe examples of the disease. 
Otherwise, the only effect which is likely to be derived from this method 
of treatment differs in no respect from that which, under similar con- 
ditions, we anticipate from the action of counter-irritation of any kind. 
Probably Dr. Churchill is quite correct when he says that, although his 
own experience is decidedly in favor of the utility of blisters, " in many 
cases turpentine fomentations will answer equally well." 

Bandages, if judiciously employed, are extremely useful in the cure 
of phlegmasia dolens. To the early stage, while the swelling is rapidly 
being doveloped, Arm bandaging is for obvious reasons inapplicable, 
and might very possibly be attended with further arrest of the circu- 
lation, and sloughing similar to what has occasionally occurred from 
careless or unskilful bandaging in surgical practice. What is at this 
period safer and more judicious is to swathe the limb in fomentations, 
which, if the pain be severe, may be sprinkled with laudanum. On 
the subsidence of the more acute symptoms, bandaging may always be 
resorted to, at first with flannel and subsequently with an ordinary 
roller bandage. What may be safely held as indicating the period at 
which bandaging is proper, is when the limb pits on pressure, this pit- 
ting being probably impossible until the permeability at least of the 
lymphatic trunks has been restored. 

Certain facts which have been observed with reference to the prog- 
ress of these cases have suggested a suspicion that, in its more severe 
varieties, or, it may be under exceptional circumstances, the affection 
may be propagated by contagion. That it may be so, when associated 
with the more serious phenomena of puerperal fever, we can readily 
believe; but we do not think that there is any evidence which would 
lead us to suppose that an ordinary case is thus communicable. The 
assertion has, however, been made upon high authority, and it will 
thus be well, even should the precaution be deemed superfluous, to take 
such means as may render any propagation of the disorder in this man- 
ner as little likely to occur as may be possible. 

From what has already been said, it may be inferred that the consti- 
tutional treatment applicable to phlegmasia dolens is to be adopted far 
more frequently to a state of general debility than to a sthenic condi- 
tion requiring antiphlogistic remedies. We speak, of course, of such 
cases as present the features of an ordinary puerperal case ; but we do 
not mean to deny that exceptional treatment may be absolutely requi- 
site to the proper management of particular cases, where marked local 
inflammation and accompanying fever of the sthenic type may call for 
prompt and energetic action. The state of the bowels must be care- 
fully attended to, and, although it will rarely be advisable to give 
strong purgatives, it is almost always necessary to regulate the dis- 
charges by gentle laxatives or enemata, and to maintain them other- 
wise in a healthy condition. Should the lochia become in any degree 



XL.] TREATMENT. 657 

offensive, simple tepid injections may be thrown into the vagina once 
or twice a day in the usual way. From a very early period of the case, 
the diet must be generous, and it will often be deemed expedient to 
give beef tea or stronger soups, and even wine from the first. During 
the period of convalescence, a similar method of treatment must be 
persevered in. 

A tonic regimen being thus clearly indicated, it is often found neces- 
sary to administer iron, quinine, and other tonics. Dr. McKenzie, with 
the view of neutralizing any septic materials which may exist in the 
blood, recommends the administration, either of hydrochloric acid, or 
of the sesquicarbonate of ammonia in full, concentrated, and frequently 
repeated doses. He directs that " an ounce of hydrochloric acid should 
be taken daily in a quart of barley or plain water, sweetened with 
syrup of ginger, and flavored with lemon-peel." 

It is by no means a rare occurrence that, in cases of this affection, 
quite unconnected with pelvic abscess or any other secondary affection, 
convalescence is extremely protracted. This, no doubt, depends chiefly, 
and in many cases entirely, on the effect which has been produced upon 
the nerves, resulting, in extreme cases, in actual paralysis of the limb. 
To the treatment of this condition, stimulating frictions are suitable, 
and it has also been recommended that, at this stage, a succession of 
small blisters be applied over the limb at various parts. Nothing is 
better, in such cases, than tepid sea-bathing, and especially the salt- 
water douche, followed by friction of the parts. There is good reason 
to believe that, in some instances of slow recovery, this is due to the 
permanent plugging of the venous trunks, or possibly to their oblitera- 
tion as the result of inflammatory action. In this case, as after deliga- 
tion of arterial trunks, it may be some time before an efficient collateral 
circulation is established, and the functions of the parts are thus but 
feebly discharged. It is much more probable, however, that changes 
take place in the clot, which ultimately result in the restoration, partial 
or complete, of the circulation within the vessel. " The blood," says 
Murphy, " has the power of separating from itself a fibro-albuminous 
element without the intervention of any membrane, and independently 
of any inflamed surface. Through this medium, the coagulum be- 
comes adherent to the sides of the vein (as in the old aneurismal sac); 
and if it be attached to the whole circumference, the inner portions 
become softened and broken down. A complete cylinder of fibrin 
may in this way be formed in the interior of a vein, through which 
(when the fluid portions of the coagulum are removed) the blood will 
circulate." We need scarcely wonder, then, that the results of treat- 
ment are often unsatisfactory, and convalescence proportionally tardy. 



42 



658 PUERPERAL INSANITY. [CIIAP. 



CHAPTEE XLL 

PUEKPEEAL INSANITY. 

NOMENCLATURE — NORMAL EFFECT OF PREGNANCY ON THE MIND — INSANITY ASSO- 
CIATED WITH PREGNANCY, LABOR, OR LACTATION — TRUE PUERPERAL INSAN- 
ITY : PATHOLOGICAL THEORIES: CONNECTION OF PUERPERAL INSANITY WITH 
ALBUMINURIA — PUERPERAL MANIA: TO BE DISTINGUISHED FROM PHRENITIS: 
IS ESSENTIALLY A DISEASE OF EXHAUSTION — SYMPTOMS : SIGNIFICANCE OF A 
RAPID PULSE: VIOLENCE: DELUSiONS — PROGNOSIS — PUERPERAL MELANCHO- 
LIA : DISTINGUISHING CHARACTERISTICS : PROBABLE TERMINATIONS — TREAT- 
MENT : PREVENTION : BLOODLETTING TO BE AVOIDED : MANAGEMENT OF THE 
DIGESTIVE FUNCTIONS: EMETICS: VASCULAR SEDATIVES: NERVOUS SEDA- 
TIVES: OPIUM, HYOSCYAMUS, CHLORAL, ETC. : DIET AND REGIMEN : SECLUSION 
AND RESTRAINT : TREATMENT DURING CONVALESCENCE : TENDENCY TO RE- 
CURRENCE AFTER SUBSEQUENT LABORS. 

The term Puerperal Insanity is here chosen in preference to the 
more familiar designation of Puerperal Mania, for the obvious, and, we 
think, very sufficient reason, that the forms under which mental aber- 
ration may occur, in the puerperal state, are various, and the propor- 
tion of cases in which the symptoms are of such a nature as to fall 
under the category of Mania, is by no means so overwhelming as to jus- 
tify the exclusive use of that name. 

It requires no very close observation of pregnancy and the puerperal 
state, to discover that the mental as well as the bodily functions are, 
in a very considerable proportion of all cases, disturbed. The psycho- 
logical phenomena to which we here refer, are far from being symp- 
tomatic of mental unsoundness, or what we may call insanity, but are 
indicative merely of the presence and operation of some disturbing influ- 
ence, dependent, doubtless, upon the condition in which the woman is 
placed. For example, it is by no means an uncommon thing — as we 
had occasion to notice in connection with the Signs of Pregnancy — for 
the temper of the woman to be changed for the worse during the course 
of a pregnancy. She becomes fretful, capricious, and, in many inde- 
scribable ways, different in disposition from what had hitherto been 
her individual characteristics. Further, the emotional faculties are less 
under control, when the causeless tears or laughter indicate an hys- 
terical disposition ; and, in other cases, the organs of special sense, and 
especially those of taste and smell, are strangely perverted, in a man- 
ner which every practitioner has had opportunities of witnessing. We 
may, therefore, venture to assume that this psychological sensitiveness 
can scarcely fail, when it exists, in some degree to predispose to a more 
serious disturbance of the mental faculties. 

Mental alienation, associated with the highest function of the gener- 



XLI.] CAUSES. 659 

ative organs, occurs under a variety of circumstances. It may thus 
manifest itself during pregnancy, in the course of labor, during the 
puerperal state, or while the woman is nursing. The insanity of preg- 
nancy is developed, in the majority of cases, between the third and the 
seventh month. It is generally characterized by melancholia, or by 
moral perversion ; and the result of treatment is, as compared with the 
other varieties, very satisfactory. What was described by Montgomery 
as the mania of labor, is rather a frenzy or temporary delirium, — the 
result, probably, of the agony which the woman suffers, or of temporary 
disturbance of the cerebral circulation. "It is not," he says, " accom- 
panied nor followed by any other unpleasant or suspicious symptom ; 
it occurs, perhaps, after the patient has been talking cheerfully, and, 
having lasted a few minutes, disappears, leaving her perfectly clear and 
collected, and. returns no more, even though the subsequent part of the 
labor should be slower and more painful. In every instance which 
came under my observation, the patients were conscious that they had 
been wandering, and occasionally apologized for anything wrong they 
might have said, although they were not aware of what the exact na- 
ture of their observations might have been." The insanity of lactation 
has been observed, in a very large proportion of cases, after the sixth 
month of nursing, — a fact which, along with the accompanying symp- 
toms, points clearly to the conclusion that the disease is the result of 
debility, proceeding from an injudicious prolongation of the period of 
nursing. It is more frequent in women over thirty years of age, and 
in those who have previously borne children, but especially so in those 
who have become repeatedly pregnant at short intervals. In this va- 
riety also, the insanity more generally assumes the melancholic than the 
maniacal type. 

The subject of true puerperal insanity is, however, that with which 
we have here more particularly to deal. This distressing affection is 
by no means of rare occurrence. According to Esquirol, about one- 
twelfth of the women admitted to the Salpetriere afforded clear exam- 
ples of this variety, while among the more opulent classes the propor- 
tion was even higher, — nearly one-seventh. But even this, we may 
be sure, gives us no idea of the much greater frequency of the disease, 
which we may well assume when we reflect that these are merely hos- 
pital statistics, and cannot, therefore, embrace the large number of cases 
w r hich occur in private practice, and which are, from first to last, 
treated at home, or under private supervision. The statistics of the 
subject further teach us, that primiparse are more liable than pluriparas, 
and that the class of cases in which susceptibility to puerperal insan- 
ity is most marked, are those in which women between the ages of 
thirty and forty a^e confined for the first time. In a considerable 
number, — it is said, indeed, in about half of all cases encountered in 
practice, — hereditary predisposition has been noted ; and it would fur- 
ther appear, that complicated and exhausting labors are much more 
frequently followed by insanity than those in which the course of labor 
has been normal. It was first pointed out by Esquirol, and the ob- 
servation has been confirmed by others, that unmarried women, who 
feel deeply the degradation of their position, are much more susceptible 



660 PUERPERAL INSANITY. [CHAP. 

than others. These, then, in addition to the functional susceptibility 
which is so characteristic of the puerperal state, may be confidently 
admitted as predisposing causes. But, as regards exciting causes, and 
the pathology of the disease, there is little upon which we can rely. 
Cold, imprudence in diet, sudden mental shock, disordered bowels, and 
a number of other similar conditions, have been generally assumed as 
causes of puerperal insanity ; but most of them, as it appears to us, on 
insufficient evidence. 

From a pathological point of view, the etiology of the subject is even 
more obscure. We may readily obtain, by observation, abundant evi- 
dence of the sympathy which subsists between the uterus and the 
cerebrum, and we need, therefore, scarcely wonder that attempts have 
occasionally been made to connect the mental disturbance with uterine 
lesion. But, although we may admit that a certain number of authentic 
cases have been advanced on undoubted authority, and were we even 
to concede that metritis may apparently be the proximate cause of 
insanity in some instances, it is abundantly evident that, in the great 
majority of cases, no such cause exists. Other instances — to which 
the same observation may apply — have been recorded, in which there 
was an apparent connection between the mental disorders to which we 
refer, and ovarian or peritoneal inflammation. Some writers — among 
whom we may mention Burns and Davis — were of opinion that the 
disease was of inflammatory origin, and described it as a modification 
of phrenitis ; but modern experience thoroughly corroborates the view 
which was taken by Gooch, "that the disease is not one of congestion 
or inflammation, but one of excitement without power," — an opinion 
which derives most ample confirmation from the narrative which he 
gives, in his admirable thesis on this subject, of eleven cases in which 
there could at no time have been any inflammation of the structures 
within the cranium. Dr. Ferrier supposed that the loss of reason, in 
most cases, was mainly due to some interference with the establishment 
of the function of lactation. On this subject he remarks : " I am in- 
clined to consider puerperal mania as a kind of conversion. During 
gestation, and after delivery, when the milk begins to flow, the balance 
of the circulation is so greatly disturbed, as to be liable to much dis- 
order, from the application of an exciting cause. If, therefore, cold 
affecting the head, violent noises, want of sleep, or uneasy thoughts, 
distress a puerperal patient before the determination of blood to the 
breasts is regularly made, the impetus may be converted to the head, 
and produce either hysteria or insanity, according to its force, or the 
exciting cause." Such a theory seems, however, in the present state 
of our knowledge, to have little to recommend it. 

One of the most interesting of modern speculations, with regard to 
the pathology of puerperal insanity, had its origin in a suggestion 
which was made by Simpson, that there might be an essential connec- 
tion between that disorder, and disease of the kidney, or at least the 
presence of albumen in the urine. That the disease may thus or in 
some other way have a toxsemic origin is, of course, perfectly possible ; 
and the theory has further a peculiar interest in connection with puer- 
peral eclampsia, in which albuminuria is a phenomenon familiar to 



XLT.] ALBUMINURIA. 661 

modern pathologists. Simpson's original suggestions on this subject, 
which were published in 1857, depended upon the observation of four 
consecutive cases, in all of which he found albumen present in the urine. 
His subsequent experience, with ample corroborative evidence from 
other sources, can leave little doubt in the mind that his first idea was 
correct, and that between the two conditions there probably exists an 
essential though inexplicable bond of association. It would appear 
that the presence of albumen is only indicated by the usual tests for a 
short time after the attack commences, and is, therefore, less persistent 
than in the case of convulsions. "The fire of disease goes on burning/' 
says Simpson, " in these cases of insanity, after the lighted match is 
merely applied, and the strange morbid clockwork runs on, as it were, 
after the key that wound it up is withdrawn. I have seen all traces of 
albuminuria in puerperal insanity disappear from the urine within fifty 
hours from the access of the malady. The general rapidity of its dis- 
appearance is, perhaps, the principal, or, indeed, the only reason why 
this complication has escaped the notice of those physicians among us 
who devote themselves with such ardor and zeal to the treatment of 
insanity in our public asylums." 

Sir J. Simpson, while making no pretence of solving what all admit 
to be a pathological riddle, seems to think that the cause of this disease 
may hereafter be discovered by the pathological chemist to consist in 
certain changes in the renal secretion, involving, secondarily, chemical 
changes in the blood itself. One well-known effect, which is apt to 
follow the appearance of albumen in the urine, is a diminution in the 
quantity of urea excreted. But, as Frerichs has shown, the mere 
presence of an excess of urea in the blood does not necessarily involve 
a septic action on the nervous system ; and the same able observer holds 
that the decomposition of urea, resulting in the formation of carbonate 
of ammonia, affords a satisfactory explanation of the intoxicating or 
poisonous effect which is produced through the blood upon the nervous 
centres in the case of puerperal eclampsia. And it is, perhaps, not too 
much to assume that this theory, if correct in the case of convulsions, 
may equally apply to the phenomena of puerperal insanity. Sir J. 
Simpson suggests further, in support of this theory, that the state of 
the blood is favorable to the occurrence of such decomposition as may 
be necessary to the formation either of the carbonate of ammonia, or 
of some other organic toxicological agent, possibly of an alhcdoidal 
character. " In the blood of the puerperal female," he writes, — 
"greatly modified as it is in the normal states of pregnancy and de- 
livery, and containing as it does after parturition the effete elements of 
the involving or disintegrating uterus, and the materials for the new 
lacteal secretion — ferments and agents may possibly exist which are 
more apt to develop special morbid poisons out of the retained renal 
excretions, than happens in other states of the system. But, I repeat, 
the whole subject is yet quite dark and conjectural, and will remain so 
till pathological chemistry is able to cast some light upon it." 

Dr. Donkin, of Newcastle, contributed a very excellent paper on this 
subject. 1 Recognizing the fact that puerperal insanity may present 

1 Edinburgh Medical Journal, May, 1863. 



662 PUERPERAL INSANITY. [CHAP. 

itself under a variety of forms, he deduces from the history of recorded 
eases, facts which appear to him to warrant the conclusion "that the 
acute dangerous class of cases are examples of ursemic blood-poisoning, 
of which the mania, rapid pulse, and other constitutional symptoms are 
merely the phenomena ; and that the affection, therefore, ought to be 
termed ursemic or renal puerperal mania, in contradistinction to the 
other form of the disease." Although most persons, familiar with 
the subject, will probably consider that Dr. Don kin goes too far in 
thus treating the matter as a fact conclusively demonstrated, his paper 
is replete with interest, and will well repay the trouble of perusing it. 

Dr. Fordyce Barker, in his recent work, asserts that in a large 
number of cases of puerperal insanity which have come under his 
observation, he has found albumen associated with so small a propor- 
tion, that he finds himself compelled to regard it, when present, as 
simply a coincidence and not a cause. It is his firm conviction that 
the mental emotions constitute the exciting cause infinitely more fre- 
quently than all other causes combined, and he adduces very interesting 
statistical facts in support of his theory. 1 

The form of puerperal insanity which is of most frequent occurrence 
is that in which the symptoms are commonly manifested within a 
fortnight after delivery, and present with greater or less distinctness 
the characteristic features of acute mania. It is to this alone — the 
paraphrosyne puerperarum of Sauvages — that the designation " Puer- 
peral Mania" can with perfect propriety be attached. Of fifty -seven 
cases noticed by Burrows, thirty-five were maniacal, sixteen melan- 
cholic, and eight alternating; and, although the relative proportion of 
cases has varied according to the experience of various writers, all agree 
that the maniacal cases are greatly in excess of the others. This is, 
no doubt, the class of cases, the observation of which by the earlier 
writers on the subject gave rise to the idea that the violence of the 
symptoms was due to inflammation. It were absurd to deny that 
phrenitis is possible in lying-in women as in others ; but no one now 
questions the accuracy of the statement made by Gooch, "that furious 
delirium from inflammation of the brain is a rare disease in childbed." 
What seems to have given, for a time, apparent confirmation to the 
inflammatory theory was the fact that, in fatal cases of puerperal 
mania, the brain was found congested. The experiments of Dr. Kelly 
upon the lower animals, and a host of pathological facts which have 
been put on record since his day, have conclusively proved to demon- 
stration, what is familiar to every modern pathologist — that death from 
haemorrhage and other exhausting causes, produces in the brain that 
very appearance of increased vascularity which, as we assume, was 
accepted by Burns, Davis, and others, as evidence of inflammatory 
action. 

Although, therefore, we admit phrenitis to be classed as a possible 
complication of the puerperal state, there is little likelihood of our 
diagnosis being obscured by such an occurrence. The very early period 
of its accession after delivery, and the manifestation of headache, suffu- 

1 The Puerperal Diseases, by Fordyce Barker, M.D., New York, 1874. 






XLI.] SYMPTOMS. 663 

sion of the eyes, and other local symptoms referable to the head, would 
doubtless indicate the nature of the disease to the judicious practitioner. 
But not only do we discard the idea of inflammation as pathognomonic 
of puerperal mania, but we embrace without hesitation a directly op- 
posite view, that it is essentially a disease of exhaustion. This is so 
far indicated by the fact already mentioned, that puerperal insanity 
in both its forms is more common after exhausting and operative 
cases, than when the progress of labor has been normal. It is further 
strongly corroborated by the details of treatment, in which we are not 
astonished to find that patients fainted after the abstraction of a few 
ounces of blood ; and by the experience of the most reliable modern 
authorities. 

The symptoms of puerperal mania do not differ in any very essential 
particular from those which are exhibited by patients who are the sub- 
jects of the same disease unconnected with the puerperal state. Still, 
there are peculiarities which are of sufficient importance to warrant a 
special description of the features of what we may call a typical case. 
The observer of psychological phenomena does not require to be told that 
there are great, and even perplexing, differences in individual instances. 
In cases in which an attack on former occasions, hereditary tendency, or 
any other cause, may particularly direct our attention to the patient; 
or when the observer has had much special experience in the treatment 
of insanity; a certain, restless, anxious manner, with more or less irri- 
tability, will sometimes presage the coming storm, and certainly one of 
the worst possible of premonitory symptoms is obstinate insomnia, or 
unrefreshing rest broken by frightful dreams. We borrow from Dr. 
Ramsbotham the following graphic description of this, and the subse- 
quent stages of the disease : 

"In mania there is almost always, at the very commencement, a 
troubled, agitated, and hurried manner,' a restless eye, an unnaturally 
anxious, suspicious, and impleading expression of face; sometimes it is 
pallid, at others more flushed than usual ; — an unaccustomed irritability 
of temper, and impatience of control or contradiction; a vacillation of 
purpose, or loss of memory ; sometimes a rapid succession of contradic- 
tory orders are issued, or a paroxysm of excessive anger is excited about 
the merest trifle. Occasionally, one of the first indications will be a 
sullen obstinacy, or listlessness and stubborn silence. The patient lies 
on her back, and can by no means be persuaded to reply to the questions 
of her attendants, or she will repeat them, as an echo, until, all at once, 
without any apparent cause, she will break out into a torrent of language 
more or less incoherent, and her words will follow each other with 
surprising rapidity. These symptoms will sometimes show themselves 
rather suddenly, on the patient's awakening from a disturbed and un- 
refreshing sleep, or they may supervene more slowly when she has been 
harassed with watchfulness for three or four previous nights in succes- 
sion, or perhaps ever since her delivery. She will very likely then be- 
come impressed with the idea that some evil has befallen her husband, 
or, what is still more usual, her child ; that it is dead or stolen ; and if 
it be brought to her, nothing can persuade her it is her own ; she sup- 
poses it to belong to somebody else : or she will fancy that her husband 



664 PUERPERAL INSANITY. [CHAP. 

is unfaithful to her bed, .or that he and those about her have conspired 
to poison her. Those persons who are naturally the objects of her 
deepest and most devout affection, are regarded by her with jealousy, 
suspicion, and hatred. This is particularly remarkable with regard to 
her newly born infant; and I have known many instances where 
attempts have been made to destroy it, when it has been incautiously 
left within her power. Sometimes, though rarely, may be observed a 
great anxiety regarding the termination of her own case, or a firm con- 
viction that she is speedily about to die. I have observed upon occa- 
sions a constant movement of the lips, while the mouth was shut ; or 
the patient is incessantly rubbing the inside of her lips with her fingers, 
or thrusting them far back into her mouth ; and if questions are asked, 
and particularly if she be desired to put out her tongue, she will often 
compress the lips forcibly together, as if with an obstinate determina- 
tion of resistance. One peculiarity attending some cases of puerperal 
mania is the immorality and obscenity of the expressions uttered; they 
are often such, indeed, as to excite our astonishment, that women in a 
respectable station of society could ever have become acquainted with 
such language." 

We have no reliable information as to the number of cases which 
prove fatal, but there is no doubt that one of the most important symp- 
toms as indicating the probability of a fatal result is extreme rapidity 
of the pulse. "Mania," said William Hunter, "is not an uncommon 
appearance in the course of the month, but of that species from which 
they generally recover ; when out of their senses, attended with fever 
like paraphrenitis, they will in all probability die." Gooch corrobo- 
rates generally this assertion, and narrates in illustration a very inter- 
esting case : " One evening, several years ago, a surgeon called upon 
me, wishing me to return with him many miles into the country, to see 
his wife, who had become maniacal a few days after her delivery. I 
was at that time attending a lady in her first labor whom I could not 
leave, but I offered to go with him if he would wait till the labor was 
over. It was going on wearily, there was no prospects of its being over 
before morning, and as he was anxious to return home, he took an- 
other physician whom I recommended. Before leaving me, however, 
he said he should like to talk with me about the case. I took down a 
volume of Dr. William Hunter's manuscript lectures and showed him 
this passage (quoted above). He said he was sorry to read it, for that 
his wife's pulse was very rapid. About a week afterwards, I heard that 
she was dead." It would appear, however, as if the views of Hunter 
and Gooch had found too literal an interpretation in many modern 
treatises, for it would almost seem to be the deliberate opinion of some 
that a rapid pulse meant death and a slow one recovery. The pulse is 
probably the most certain indication which we have ; but it is not to be 
relied upon solely, to the exclusion of others. Extreme rapidity in the 
beats is in this, as in all the other more serious disorders of the puer- 
peral state, a symptom of grave import ; but too much has been made 
of it; and for our part, we are quite convinced that there are many 
cases in which the pulse rises above 120, and remains at that rate for 
days in succession, and yet convalescence is ultimately quite satisfactory. 



XLI.] SYMPTOMS. 665 

When the pulse suddenly rises at the commencement of the attack, the 
symptom is undoubtedly more alarming. 

In the worst cases, the milk and lochia are entirely suppressed ; but 
this is not usually the case, although both functions are more or less 
interfered with, the nutritive value of the milk, at least, being generally 
deteriorated. There is obstinate insomnia, which often defies the calm- 
ing influence of the strongest drugs. The digestive functions become 
impaired in a marked degree, the tongue being furred, and the odor 
of the breath not unfrequently offensive. The urine is scanty and high- 
colored, and the alvine evacuations are offensive — there being some- 
times diarrhoea, but more frequently constipation. The cases in which 
the patient is extremely violent are exceptional ; but it is often im- 
possible, or at least a matter of great difficulty, to induce her to remain 
silent or at rest. She insists on rising to discharge some imaginary 
neglected household duty, and her delusions may turn into all kinds of 
odd channels. She in many instances refuses food, and it may, on this 
account, even be necessary to use force in order that such nutriment as 
is essential to maintain life may be introduced into the stomach. The 
delusion, in one very obstinate case of this nature which came under our 
observation, was, that putrefaction was going on internally, and that 
food only tended to supply material for the morbific process ; and in 
other cases it has been noticed, that, although the patient obstinately 
refused food when urged to take it, she would, if she could obtain it 
furtively, take it greedily and voraciously. Again, a prominent char- 
acteristic of these cases, which adds greatly to the responsibility of 
their management, is the undoubted tendency to suicide, which may 
show itself in many ways, although hidden with all the craft and cun- 
ning of insanity. 

It has been remarked as a feature characteristic of puerperal mania, 
that, occasionally, the woman, although her mind is pervaded by delu- 
sions, has a strange underlying conciousness that her thoughts and 
actions are under the influence of some mysterious power. It has been 
stated, that seldom or never is this consciousness of a delusion mani- 
fested in other forms of insanity. Gooch states that the symptoms, in 
some cases observed by him, closely resemble those of delirium tremens, 
and he has also seen symptoms, of the nature of catalepsy, which were 
associated with distinct puerperal mania. If we may accept as prob- 
able the theory to which allusion has already been made, — that albu- 
minuria, in mania as well as in eclampsia, points to the proximate 
cause, — we cannot be astonished to find that clinical experience in some 
measure seems to indicate a connection between them. We even find, 
that by some the expression " epileptic puerperal mania" has been em- 
ployed as indicating the occasional coincidence of the phenomena of 
eclampsia with those of mental aberration. In some instances the 
mania has been preceded by convulsions, while in others the mental 
phenomena have been the, first to develop themselves. 

The Prognosis of these cases involves, as will readily be understood, 
questions of deep interest in individual instances. As regards the risk 
to life, it is, as we have attempted to show, an error to suppose that a 
rapid pulse is necessarily the forerunner of death. But there is another 



QSQ PUERPERAL INSANITY. [CHAP. 

error, which at one time led to a contrary belief. This finds expression 
in a remark which Dr. Gooch attributes to Dr. Baillie, who, when con- 
sulted about a case, remarked " that the question was not whether she 
was to get well, but when she was to get well." To this Gooch adds 
dryly, "the patient died a week after this prognosis." The fact is, 
that death from puerperal insanity does now and again occur, and more 
frequently from the maniacal than from the melancholic form. Dr. 
Churchill says that he should himself lay great stress, in forming a 
prognosis, upon the presence or absence of uterine complication; and 
the observation, coming from such a source, merits careful attention. 

The question of prognosis involves not only the danger to life, but 
the prospect of speedy restoration to reason. In this respect, in so far 
as mania is concerned, we may look forward with considerable confi- 
dence, especially in the absence of hereditary predisposition, to an early 
recovery. " Within three weeks," says Dr. J. B. Tuke, 1 " or more fre- 
quently earlier, the mania gradually subsides, and is replaced by a state 
of dementia, generally accompanied by delusions, which almost invari- 
ably assume the form of mistaken identity. These gradually disappear, 
leaving a haziness of apprehension, and a state suggesting the idea of 
waking from a dream. The patient can now, generally, be induced to 
work, and otherwise employ herself. From that moment you may 
look with almost certainty to ultimate recovery." There are cases, 
however — chiefly those of hereditary taint — in which the delusions be- 
come confirmed, and in which, although the general health may have 
been quite restored, the mental aberration is persistent. Dementia, of 
a more serious nature than that mentioned by Tuke, gradually takes 
the place of mania, and hopeless chronic insanity is the result. 

Although in the insanity of pregnancy the majority of cases are of 
the melancholic type, it is otherwise with true puerperal insanity; 
where melancholia, although by no means rare, is, as compared with 
mania, comparatively unfrequent. Few cases which, from the first, 
come under this category, present characteristic symptoms earlier than 
the sixteenth day, and a large proportion of cases come on considerably 
later than this. All at first may go on to our perfect satisfaction : the 
patient has been able to leave her bed at the usual time ; her appetite 
is good ; she sleeps well, and is able to nurse her child ; it is assumed 
on all hands that convalescence has been satisfactorily established. 
Perhaps a month after the birth of the child, a change comes over the 
mother, which, to her attendants, is quite inexplicable. The pride 
and interest in a firstborn child gradually fades away, and a cloud of 
sadness, utterly without cause, slowly spreads itself over the aspect 
and demeanor of the mother. Causes, which are either imaginary, or, 
if real, are of the most trivial character, give rise to fits of silent weep- 
ing, during which the patient is not demonstrative, and rather avoids 
than seeks sympathy. The gloom deepens as the curtain falls. No 
longer does the cry of the infant awaken a tender sympathy in her 
heart; on the contrary, she maintains a moody silence, and not only 
never inquires for her infant, but seems to look upon it with actual 

1 Edinburgh Medical Journal, May, 1865. 



XLI.] MELANCHOLIA. 667 

aversion. Delusions — all of the melancholic type — if they have not 
already manifested themselves, now become apparent. She believes 
that in marrying she has violated some important moral obligation. 
While she heaps all sorts of accusations on her own head, she compara- 
tively rarely complains of others. Too frequently the religious element 
enters into her morbid ponderings, and she fancies herself lost, and her 
soul beyond all hope of salvation. 

And not by day only, but by night, do these gloomy impressions 
weigh upon her mind, so that sleeplessness is an early and most trouble- 
some symptom, resisting often all the ordinary methods of alleviation. 
The appetite fails, or becomes capricious ; or she may absolutely refuse 
to take any nourishment, except upon earnest solicitation, or even the 
employment of force. As the lochial discharge has most likely ceased 
before the symptoms of insanity make their appearance, no reference 
need be made to that; but, as regards the lacteal secretion, it will 
generally be observed that, even in robust women, who previously had 
an abundance of milk, it is rapidly arrested, and the breasts become 
flaccid. The bowels are sometimes tolerably regular, but, as a rule, 
are constipated, and the dejections foetid. The urine is high in color 
and scanty, unless there is an hysterical element in the case, when there 
may be a great flow of a low specific gravity. The pulse may be 
accelerated, but is seldom so continuously. In some instances, symp- 
toms of moral insanity are prominent. In cases in which there has 
been — even long previously — a tendency to intemperate habits, these 
may reappear, in the earlier stage, in the form of aggravated dipso- 
mania, in which the morbid craving for stimulants may assert itself in 
the most intense form ; and the patient will, if unable to procure ordi- 
nary stimulants, greedily consume eau-de-Cologne, spirits of sal vola- 
tile, valerian, or spirits of lavender, should such be left within her 
reach. And, in like manner, the pica of pregnancy may appear in an 
exaggerated form, when she will eat soap, or even more disgusting 
substances which may be at her command. 

The progress and ultimate issue of such a case are matters which give 
cause for deep apprehension. It is not a fatal result that we dread so 
much as permanent insanity. The observation of Gooch on this point 
merits the dignity of an aphorism, when he says that "mania is more 
dangerous to life, melancholia to reason." When the two varieties — 
mania and melancholia — are considered together, it has been said that 
the period of convalescence ranges from a few days to two years ; but, 
if we take the trouble to analyze the cases, and separate the one class 
from the other, it will become quite obvious that the examples of pro- 
tracted convalescence are, almost invariably, those in which melancholy 
has been the prevailing type. And, in like manner, if we avail our- 
selves of such statistical observations as may seem most reliable, it is 
equally clear that the melancholic cases afford by far the greater num- 
ber of those instances in which reason has permanently succumbed. In 
so far as we can gather from the observations of those who have given 
most attention to the subject, it would seem that the existence of albu- 
men in the urine has no such marked association with puerperal melan- 



668 PUERPERAL INSANITY. [CHAP. 

cholia as it has with mania of the same class ; but this is a point in 
regard to which more extended clinical study is still required. 

Treatment. — From every aspect of the case, the treatment of puer- 
peral insanity is a subject of surpassing clinical interest, and One which 
deserves, we venture to assume, more attention than has, in some sys- 
tematic works, been accorded to it. This is particularly the case as 
regards prevention; for we can scarcely doubt that, when the symp- 
toms are such as to indicate disturbance of the cerebral functions, much 
may be done, in the way of warding off an attack, by a judicious em- 
ployment of the remedies to be hereafter mentioned. This remark 
applies chiefly to cases where there is a marked hereditary taint, or 
where the patient has been insane at previous confinements. An illus- 
tration of the latter came recently under the notice of the writer. 

A delicate lady, who had married very young, became insane (mani- 
acal) about ten days after her first, and nine days after her second con- 
finement, and on the latter occasion the convalescence had been ex- 
tremely protracted, and the danger to life at one time great. Much 
anxiety was naturally felt by herself and her friends on the approach 
of a third confinement, particularly as, towards the end of the ninth 
month, she became hysterical, sleepless, and melancholy, as on the 
former occasions. A very remarkable feature in the case was the ten- 
dency to dreams of a disturbing kind, which not only rendered such 
sleep as she obtained un refreshing, but made her actually dread falling 
asleep. The state of the tongue and dejections indicated considerable 
derangement of the digestive functions. As the period of expected 
delivery approached, the symptoms became still more marked; but 
they seemed to be, in some degree, under the control of the remedies 
which were adopted, — the most effectual being hydrate of chloral for 
the nervous symptoms, and colocynth with hyoscyamus for the bowels. 
Labor passed over quite favorably and in every respect satisfactorily, 
the patient being, however, as might have been anticipated, very feeble 
and exhausted after its completion. After delivery, very strict pre- 
cautions were observed to maintain perfect quietness, and freedom from 
any possible worry or annoyance. A certain amount of sleep was ob- 
tained by chloral : opium made matters worse. The child was not put 
to the breast, and the lacteal secretion was easily kept under. It was, 
in this case, a matter of intense interest to watch the struggle for reason ; 
for, although at no time did she exhibit symptoms of insanity, there 
was not the slightest doubt that she was on the verge of it ; but, hap- 
pily, after a fortnight had elapsed, she rapidly improved, her appetite 
increased, and she enjoyed natural and refreshing sleep ; until ere many 
more days had passed, she was pronounced convalescent. It is too 
much to expect that this narrative proves that an impending attack of 
mania was warded off; but the impression is, nevertheless, fixed on 
the minds of those who watched the case, that constant and anxious 
supervision, and above all, skilful and judicious nursing, saved the 
patient from a recurrence of her former malady. 

The cases, however, in which preventive treatment can be expected 
to be of much avail, are probably of very rare occurrence ; and there, 
no doubt, is a danger — against which we would caution the inexperi- 



XLI.] TREATMENT. 669 

encecl — of looking with apprehension upon what our fears may magnify 
into premonitory symptoms, and thus adopting, on insufficient grounds, 
methods of treatment, upon the successful results of which we com- 
placently congratulate ourselves. 

The symptoms which accompany a violent attack of puerperal mania 
— when there is rapid pulse, heat of head, and great cerebral disturb- 
ance — are such as very readily to explain how, for so long a period, 
the lancet was employed as a measure of the veriest routine. Apart 
from the theory of phrenitis, the very violence of the symptoms seemed 
to demand prompt and free bloodletting. The change which public 
and professional opinion has undergone during the last forty years is, 
however, such that we scarcely think it necessary to recommend caution 
in regard to this once familiar remedial measure. Were it otherwise, 
we might point to many facts which conclusively prove that puerperal 
mania is essentially a disease of debility ; and that, if the heat of head, 
and other local symptoms, should seem to suggest the application of 
leeches to the temples, even this practice must be adopted with the 
greatest possible caution ; for cases have undoubtedly occurred, in 
which a very moderate loss of blood has precipitated a fatal result. In 
cases of actual phrenitis, bloodletting is, of course, in some form or 
other, urgently demanded ; but no real difficulty should prevent the 
discrimination of these very rare cases from the ordinary varieties of 
puerperal mania. 

The gastro-intestinal disturbance, which is so invariable an accom- 
paniment of the case, requires, from the first, careful attention, and 
generally prompt treatment. If the bowels, therefore, are overloaded, 
a purgative should at once be administered ; and, although we must not 
expect an immediate cure, as in one of Gooch's cases, we may look for 
some relief in the symptoms, and especially of the irritability and rest- 
lessness so characteristic of the disease. But it will not suffice simply 
to see that the bowels are thoroughly cleared of their contents, which 
are often highly offensive ; for, be the case long or short in its duration, 
the judicious regulation of the bowels is one of the most important 
indications of treatment. For this purpose, aloetic purgatives are 
appropriate, from their derivative action. It would appear that, in 
some cases, signal benefit has been derived from the administration of 
emetics. " If the powers of the constitution are not low, and the gas- 
tric symptoms are very marked — namely, a foul tongue, an offensive 
breath, and a yellow eye — an emetic, not of antimony, but ipecacuanha, 
may be given." So wrote Gooch, and most modern writers have re- 
peated his recommendation of emetics, at least as an exceptional method 
of treatment. Care must be taken, of course, not to administer those 
depressing agents when the face is pale, the skin cold, and the pulse 
quick and weak ; and, indeed, the more prominently we keep before 
us the leading fact, that puerperal insanity is a disease of debility, the 
less likely will we be to have recourse to antiphlogistic remedies. 

Although bloodletting is, for reasons already fully explained, contra- 
indicated, there is often observable such a degree of vascular excite- 
ment, that we may naturally inquire whether this cannot be allayed by 
some safer measures. The application of cold to the head, or what is 



670 PUERPERAL INSANITY. [CHAP. 

even better, laving the forehead and temples with warm water — after 
which there is a refreshing feeling of coolness — may produce the de- 
sired effect. In other cases, we may administer any of the vascular seda- 
tives, of which none, probably, will be more likely to effect the pur- 
pose we require than tartar emetic, in such doses as may be necessary 
to produc a depressing effect — taking great care, for obvious reasons, 
not to push it too far. One or two drops of the tincture of aconite, or 
of the tincture of veratrum viride, have been recommended by Simp- 
son for the same purpose. 

Undoubtedly, the most important remedies to which we have to refer 
are the class of nervous sedatives. At the head of the list stands opium 
— the sheet-anchor, as it has been called, of the alienist physician. It 
is to be observed, however, that there exists a considerable diversity of 
opinion as to the propriety of administering opium in the puerperal 
varieties of insanity. It is quite certain that in some cases it proves of 
no avail, while in others the result is the reverse of beneficial. Simpson, 
who admits this, says, " Whatever may be the way in which you give 
the drug, remember always, as the general rule to guide you in its ad- 
ministration to such patients, that it must be given in very large doses. 
If you expect to have any good effect from it, you must give, in gen- 
eral, not less than two or three grains of solid opium, or an equivalent 
dose of some of the cognate preparations." If unusual difficulty is 
encountered in the administration of the drug in the ordinary way by 
the mouth, the same authority recommends the introduction into the 
rectum of a suppository containing one or two grains of morphia ; and 
he mentions an interesting case in which that was followed by a sleep 
of sixteen hours, from which the patient awakened quite free of ma- 
niacal symptoms. Dr. Tuke observes that the exhibition of opium, as 
well as of the other narcotics, is not beneficial when the leading symp- 
tom is acute mania; and it is w T ell that we should bear this observation 
in mind as coming from one of much experience in the treatment of all 
forms of insanity. In some instances, chloroform has been employed 
with much benefit, the patient being brought fully under the effect of 
the anaesthetic, a little more being given from time to time as she seems 
about to awake. Hyoscyamus, in combination with ether or ammo- 
nia, and Indian hemp, have also been employed with the same, object. 
Camphor was Gooch's favorite remedy, but it is not now so frequently 
employed as at one time it was. The hydrate of chloral is another 
remedy which has of late, to some extent, superseded opium in the 
treatment of insanity, as in many other disorders ; and experience 
seems to show, that in this drug Ave have a most important addition to 
the materia medica of the class of diseases in question. The use of the 
warm bath should not be forgotten in an enumeration of sedative 
agents, and there can be no doubt, that by it a beneficial effect is pro- 
duced even when drugs have failed. Let us always remember that the 
primary objects which we have in view, in the exhibition of this class 
of remedies, is to procure sleep. If we succeed in our object, the pa- 
tient may at once recover ; but, unfortunately, as a rule, she relapses, 
on awaking, into the violence and delusions of her unhappy state. 

As regards diet, unless deterred by special circumstances, such as 



XLI.] SECLUSION. 671 

gastric or intestinal derangement, we should at once permit the use of 
soups in moderation, along with other substances of easy digestion 
which may suggest themselves. In many cases, a small quantity of 
wine may be added, about two ounces, perhaps in the first instance, to 
be increased as the necessities of the case may seem to require. As the 
case goes on, it will generally be proper to give more generous diet, 
and to be more liberal, it may be, in the use of stimulants ; for we may 
be perfectly sure, that, as this was a disease of debility from the first, 
an improved physical condition is an essential concomitant of recovery. 

The general management and control of the patient involves the im- 
portant points of seclusion and restraint. Our aim, in this respect, is, 
above all, to guard the woman from whatever may prove a source of 
excitement. The experience of every one clearly proves, that to permit 
of free association with relatives and friends is, in the highest degree, 
injudicious. Such interviews give rise to excited appeals as to being 
relieved from the irksomeness of restraint, and generally awaken in the 
mind painful impressions, which leave the patient for a time in a worse 
mental condition than before. In most cases, therefore, in which the 
symptoms show unusual obstinacy, it is well to separate the patient 
from her friends and to leave her entirely to the management of those 
who have special experience in the treatment of the insane. This should, 
if possible, be done in her own house, for we confess to a great reluc- 
tance to send persons suffering under this comparatively curable variety 
of insanity to be immured in a lunatic asylum, to associate, probably, 
with persons whose minds are also deranged. We do not deny the ad- 
vantage of a system of constant and intelligent supervision, but if this 
can be equally well secured at home, it is always well to avoid the 
stigma which attaches to confinement in an asylum, and which many 
women, after their recovery, will feel most acutely. As reason is grad- 
ually being restored, too great caution can scarcely be exercised in per- 
mitting her to renew her intercourse with her friends ; and, if it should 
seem that interviews with them still excite her, the period of seclusion 
must be extended. There are cases, however, in which the visit of a 
relative or friend has the best possible effect, in diverting the mind 
from its morbid condition into channels which are more healthy, by 
reason of the association of ideas which recall the past. It is at this 
stage that change of air and scene is more particularly beneficial. Dur- 
ing the whole course of treatment, the patient should not be left for a 
moment alone, and, as a prominent characteristic in such cases is suicidal 
impulse, it is always proper to see that nothing be left within her reach 
which might render self-injury possible. 

The treatment of melancholia differs in some respects from what has 
been prescribed as proper to the maniacal variety. There will, for 
example, in cases which manifest this type of insanity, be no necessity 
for the use of any of the vascular sedatives, as the circulation is little, 
if at all disturbed. From the first, therefore, we should adopt a more 
nutritious regimen than in the other and more frequent cases; but, 
unfortunately, we must look forward to a long illness and lingering 
convalescence, and in some unhappy instances, to the symptoms gradu- 
ally being merged in those of hopeless dementia. It will more frequently 



672 PUERPERAL ECLAMPSIA. [CHAP. 

be found necessary, in the melancholic cases, to remove the patient from 
home, and even to place her in strict confinement. 

The question of the recurrent nature of the disease is the only other 
point upon which we need touch ; and it is one in regard to which 
authors do not seem to be agreed. Gooch thinks that it is unusual; 
but a careful observation of such meagre statistical facts as are at our 
command seems to point strongly to the conclusion, that there is a 
decided tendency to the recurrence of the disease in the subsequent 
pregnancies of women who have previously been the subjects of puer- 
peral insanity. It is in cases in which there is hereditary taint that 
this is most distinct, but the tendency in all cases is sufficiently marked 
to warrant us in taking every precaution to avoid the other exciting or 
predisposing causes of the disease. Tuke's cases were recurrent in the 
proportion of fifteen out of seventy-five. 



CHAPTER XLIL 

PUEEPERAL ECLAMPSIA. 

DEFINITION — CONNECTION BETWEEN ECLAMPSIA AND ACUTE BRIGHT'S DISEASE — 
ECLAMPSIA FROM OTHER MORBID CONDITIONS — EFFECTS OF PREGNANCY ON 
THE SYSTEM — PERIOD OF EXPLOSION — SYMPTOMS: PREMONITORY SIGNS; 
OiDEMA, ALBUMINURIA, CEPHALALGIA, ETC. — PHENOMENA OF THE FIT: 
PERIOD OF TONIC AND CLONIC CONVULSIONS, AND OF COMA — PATHOLOGY: 
ALBUMINURIA: DECOMPOSITION OF UREA, AND FORMATION IN THE BLOOD 
OF CARBONATE OF AMMONIA: EFFECTS OF PRESSURE ON THE RENAL VEINS: 
DETECTION OF ALBUMEN IN THE URINE — MORBID ANATOMY — EFFECT OF 
LABOR PAINS — MATERNAL AND FCETAL MORTALITY — PROGNOSIS : IN ECLAMPSIA 
GRAVIDARUM, PARTURENTIUM, ET PUERPERARUM — TREATMENT: PROPHY- 
LAXIS: USE OF ACIDS: PURGATIVES AND DIURETICS: INDUCTION OF PREMA- 
TURE LABOR: TREATMENT DURING THE FIT: BLOODLETTING; CHLOROFORM; 
CHLORAL : OBSTETRICAL TREATMENT AT VARIOUS STAGES OF LABOR; ACCELE- 
RATION ; RUPTURE OF THE MEMBRANES ; USE OF THE FORCEPS. 

Under the designation of Puerperal Eclampsia are included, not 
only such instances of the malady in question as are manifested during 
the puerperal period, but all cases, without exception, which are observed 
in the course of pregnancy, during labor, or after delivery. It was for 
this reason that we deferred any notice of Eclampsia as a complication 
of gestation or delivery, until, having the whole subject before us in 
its broadest aspect, we should be in a position to review the highly 
interesting speculations to which modern pathology has of late so 
largely contributed. 

It is scarcely necessary to remark that the affection which we are 
now about to consider does not include all cases, without exception, in 
which symptoms of the convulsive or epileptiform type manifest them- 






XLII.] ECLAMPSIA. 673 

selves during pregnancy or childbed. It is, for example, a disorder 
distinct from, although, in its more conspicuous phenomena, closely 
analogous to epilepsy. But, so great is the preponderance of cases in 
which the symptoms of true puerperal eclampsia exist, that we think 
we are perfectly justified in agreeing with those who look upon a certain 
train of symptoms and pathological facts as essential, or nearly so, to 
the disease in question. " Eclampsia puerperalis," says Braun, "is an 
acute affection of the motor function of the nervous system, charac- 
terized by loss of consciousness and of sensibility, by tonic and clonic 
spasms, and occurs only as an accessory phenomenon of another disease, 
generally of Bright's disease in an acute form, which, under certain 
circumstances, spreading its toxaemic effects on the nutrition of the 
brain and the whole nervous system, produces those fearful accidents. 
The toxaemia (or blood-poisoning) in eclampsia gravidarum, parturen- 
tium et puerperarum, is commonly produced by uraemia; i. e., by a 
change of urea which is retained in the blood, or by retention of the 
excrementitious constituents of the urine. . . . Under the common 
appellation of ' Eclampsia 7 several pathological processes have hitherto 
been comprehended, which do not even present an identical series of 
symptoms, and which have only this in common, that there exist tonic, 
and specially clonic spasms, along with loss of sensibility." 

The exceptional varieties of eclampsia, to which the author here 
refers, are cases in which the origin is to be discovered in defective 
purification of the blood, arising from quite different causes — such as 
imperfect elimination of carbonic acid through the lungs, the retention 
of bile in the blood (cholcemia), or the operation within that fluid of 
certain other septic agents — the nature of which is little understood — 
such as are developed occasionally in the course of typhus, or some 
other continued fever. Epilepsy, when it occurs, is to be distinguished 
partly by the symptoms of the attack, but more particularly, if not con- 
clusively, by the absence of albumen in the urine, both before and after 
the attack. Cases have been met with, in which the cause was pre- 
sumed to reside in an altered condition of the blood, as regards the 
proportion of its various normal ingredients — such as hyperinosis, 
leukaemia, or hyclraemia. One of the symptoms which immediately 
precede dissolution, in cases of haemorrhage, is a convulsive seizure, 
presenting most of the features of eclampsia, and supposed by most 
authorities to be due to anaemia. Finally, and putting aside the cases 
in which convulsions are due to some diseased condition or functional 
disturbance of the nervous centres, there are other instances, in which 
an irritation of the peripheral nerves gives rise, by a reflex action, to 
similar symptoms, which are often associated with other hysterical 
manifestations, and are therefore called, with some propriety, hysterical 
convulsions. With rare exceptions, then, arising from these or similar 
causes, puerperal eclampsia may be looked upon as essentially connected 
with uraemic poisoning, which, again, is associated with, or dependent 
upon, an albuminous condition of the urine. 

Before entering upon the consideration of the symptoms and pathology 
of this alarming disorder, it may be well to look closely, were it but 
for a moment, upon some of the conditions essential to the pregnant 

43 



67-4 PUERPERAL ECLAMPSIA. [CHAP. 

state. The constitutional sensitiveness, to which we have already 
more than once referred as eminently characteristic of pregnancy, can 
scarcely fail to display itself in its relation to the nervous system and 
its all-pervading influence. Dr. Barnes has quite recently 1 argued, 
with much force and great ingenuity, in favor of a theory which he 
advances, that nature provides, against the period of parturition, a 
special supply of nerve-force; that this is associated with an increased 
irritability of the nervous centres; and that it implies a corresponding 
organic development of the spinal cord. This involves, we apprehend, 
pretty much the same idea as that which we have expressed, although 
it is couched in more precise and more philosophic terms. What more 
likely, may we not infer, than that the force of the nervous system thus 
surcharged may, by derangement of excited signals, be reflected upon 
the wrong track, and thus cause convulsive action in unlooked-for 
quarters, and frequently disaster as the result? But, besides this, we 
cannot but regard the altered condition of the blood in pregnant 
women, as, in some degree, predisposing to a morbid condition, one of 
the essential factors of which is an abnormal state of the blood itself. 
These changes, as formerly mentioned, consist in an increase of water 
and of fibrin, a diminution in the quantity of albumen, and a reduc- 
tion in the proportion of the red, with a relative increase in the white 
corpuscles. 

There is another point of great interest, to which Barnes directs 
attention in his lectures above alluded to, — that all generative acts 
manifest an emotional and a convulsive element. "It further deserves 
to be noted here, that emotion takes a large part in every act or process 
^f the generative function. In short, emotional affectability is the 
measure of convulsive liability. Another proposition I would state is 
the correlative of the preceding one. It may not be quite so obvious 
dn its truth, but I think I shall be able to show that it is equally con- 
stant. It is this : An energy which may be compared with, if not 
identical in nature with, convulsion, is an essential element in the 
leading acts of the generative function. I have known instances of an 
epileptic fit being repeatedly induced by the sexual act. I have heard 
of several other like cases. Voisin mentions one. La Motte knew a 
woman who, not pregnant, always vomited sold actione coitus." 

The period at which eclampsia most frequently develops itself, is 
generally stated to be during the course of labor. As, however, it is 
also noticed for the first time during the last weeks of pregnancy in a 
large number of cases, and as labor is often an immediate result of a 
convulsive seizure, it cannot be an easy matter to determine what is its 
relative frequency with regard to the three periods of pregnancy, labor, 
and childbed. According to Braun and Wieger, more than half of all 
cases occur during labor, but, for the reason above stated, this may well 
be admitted as doubtful ; and, for our part, we are inclined to agree 
with the conclusions of the writer of the able article on this subject in 
the Nouveau Dictionnaire de Medecine et de Chirurgie Pratiques, that 

1 See his Lumleian Lectures on the Convulsive Diseases of Women Lancet, 
April, 1873. 



XLII.] ' SYMPTOMS. 675 

the relative frequency of the three epochs is correctly expressed in the 
following order, — pregnancy, labor, after delivery. Statistics are not 
much to be relied upon, but it may be noticed that an average of Eng- 
lish and Continental practice seems to yield about 1 case of eclampsia 
in 350 labors. 

Symptoms. — Although the convulsive seizure sometimes comes on 
quite unexpectedly, there are probably few cases in which premonitory 
symptoms of some kind or other might not have heen detected. One 
of the most important of the premonitory symptoms is oedema, which, 
indeed, is of common occurrence, especially in the ankles, feet, and 
labia majora. This oedema is generally developed some weeks before 
the appearance of the first fit, and it is occasionally, although somewhat 
rarely, to be observed in the upper part of the body and in the face. 
Should this symptom be manifest, the suspicion of the attendant will, 
almost as a matter of course, be excited, with the result of an immediate 
examination of the urine, which will be found to yield a large quantity 
of albumen by the ordinary tests of heat and nitric acid. The micro- 
scope, in most of these cases, reveals the presence in the fluid of hyaline 
tube-casts, with or without blood-corpuscles ; or it may indicate, by 
appearances familiar to the pathologist, the presence of more advanced 
and serious renal disorder. 

In a considerable number of instances, no oedematous indication 
attracts attention, even although undoubted albuminuria exists; but, 
when this more conspicuous and familiar symptom is absent, there are 
other premonitory symptoms, which in some cases are of high impor- 
tance, and, in all, demand careful attention. According to Chaussier, 
there are three symptoms which, as premonitory indications, deserve 
special attention : these are cephalalgia, derangements of vision, and 
epigastric pain. The headache — which is the most frequent of all — is 
extremely acute, and is usually complained of in the frontal region. 
At first it is intermittent, but subsequently, and especially when the fit 
is near at hand, the pain often becomes continuous. When the sense 
of sight is any way disturbed, this is justly looked upon as an indica- 
tion of grave import. There is, at first, either cloudiness or dimness 
of vision, or that peculiar indistinctness which gives one the idea of 
looking through the highly rarefied atmosphere over a furnace — familiar 
to those who are the subjects of trifling biliary derangements. In other 
examples, objects seem to exhibit peculiar colors, and the vision becomes 
gradually more impaired, although in some instances the affection is 
intermittent. Very often the loss of sight does not come on till imme- 
diately before the fit, and cases have probably been witnessed by most 
practitioners of experience, in which a patient, either during labor or 
before it, complains of sudden and complete loss of vision, and in a few 
minutes, or it may be seconds, is overwhelmed with the most violent 
eclamptic seizure. The third of the premonitory symptoms of Chaus- 
sier, epigastric pain, is of less frequent occurrence than the other two. 
The suffering is described as being extremely severe, lasting often for 
hours ; and when it is of unusual severity, it is said to be an almost 
certain precursor of a convulsive attack. In no inconsiderable propor- 



676 PUERPERAL ECLAMPSIA. [CHAP. 

tion of all cases of the affection, no albumen is to be detected, and this 
is a fact which must be carefully borne in mind. 

The convulsive seizure characteristic of true puerperal eclampsia 
varies so little, save in intensity and duration, that to have witnessed 
and carefully observed even a single attack will suffice to make one 
familiar with its main diagnostic; features. The following description 
of the fit is in a great measure borrowed from the essay already alluded 
to. Probably, after some of the precursory symptoms already described, 
the patient seems deeply absorbed and preoccupied ; then her gaze be- 
comes fixed for a few seconds, and the fit commences immediately by 
rapid contractions of the muscles of the face, of the 1 eyelids, and of the 
eyeballs, which seem to roll in their sockets. These twitching move- 
ments, which give to the countenance a most painful expression, pres- 
ently give place to tonic contractions of the same muscles, and of the 
neck. The mouth is first twisted towards the left, and the face is slowly 
turned towards the shoulder of the same side. The upturned eyeballs 
show, through the half-closed eyelids, the inferior segment of the scler- 
otic. After being slowly turned to the left, the face, by a movement in 
the contrary direction, turns towards the right shoulder. From the 
head, the convulsive phenomena rapidly extend to the other parts of the 
body. The extensors of the trunk, thrown into violent contraction, 
tend to bend the spinal column backwards (opisthotonos). The trunk 
becomes perfectly rigid. The legs are equally so and generally extended. 
The hands close with force, the thumb being bent inwards upon the 
palm, and grasped by the other fingers. Occasionally, the predominant 
action of the flexor muscles has the effect of fixing the different seg- 
ments of the superior extremities in a semiflexed position, so that the 
arm sometimes takes the attitude which is given to it to protect the head 
from a menaced blow. Finally, the diaphragm and the respiratory 
muscles become involved. Respiration is suspended ; the face becomes 
livid; and the tongue, if projecting from the mouth at the commence- 
ment of the fit, is seized and lacerated by the spasmodic closure of the 
jaws, and the blood, which escapes from the wound thus produced, 
tinges the saliva which flows from the lips. The muscles of the larynx, 
and possibly those of the throat, being strongly convulsed, close these 
orifices. Consequently, the air, compressed by the convulsive constric- 
tion of the thorax, can only escape with great difficulty, and produces 
a peculiar intercepted hissing expiration. There is observed, at the 
same time, a complete loss of consciousness and of all sensation. The 
patient neither sees nor hears; and if we pinch or burn the skin, she 
makes no attempt to withdraw from an irritation of which she does 
not seem to have the slightest perception. 

Clonic convulsions, affecting the whole muscular system, soon succeed 
the tonic variety. Jerking movements of the head, trunk, and limbs, 
take the place of the general rigidity of the preceding period. Fright- 
ful contortions of the countenance are the result of irregular movements 
of the mouth, eyelids, and eyeballs. Respiration, which up to this 
point is almost completely suspended, becomes gradually re-established. 
The expiratory act is interrupted and stertorous ; a frothy, and often 
bloody foam is forced from between the lips. The movements of the 



XLII.] PATHOLOGY. 677 

trunk and limbs consist of twitcliings, so trifling in extent as merely to 
move the body without displacing it, so that there is not the same 
necessity for restraint as in some other convulsive diseases. The pulse, 
if strong and full at the commencement of the fit, is rapidly accelerated 
under the influence of the muscular and respiratory disturbance, and 
becomes extremely feeble towards the height of the paroxysm. It 
sometimes happens that the contents of the bladder and rectum are 
voided during the fit, either by paralysis of the sphincter, as some have 
supposed, or by convulsive action of the diaphragm or the muscles which 
form the abdominal walls. 

As the fit passes off, all these symptoms progressively decline. The 
balance of the respiratory and circulatory functions is restored ; the color 
of the surface becomes natural; the movements of trunk and limbs be- 
come feebler and less frequent, and finally cease. In a word, the con- 
vulsive manifestations of eclampsia may be divided into two distinct 
periods. The first, which is characterized by tonic convulsions, seldom 
lasts more than twenty or thirty seconds : the second period, that of 
clonic convulsions, lasts much longer — from one to five minutes, or even 
more. The gradual restoration of the respiratory function during this 
second period, prevents any special danger to life ; and it is, therefore, 
during the first, or tonic period only, that there is immediate risk. 
After the fit has entirely ceased, the patient remains in a comatose con- 
dition, the depth and duration of which is in proportion to the intensity 
of the paroxysm, so that the patient may regain consciousness in a few 
minutes, or after the lapse of many hours. A dull languor, or a con- 
fused feeling, with headache, is then very generally complained of, and 
it may thus be some time before the patient completely recovers. This 
is, of course, supposing that she has but one attack, or that a consider- 
able interval occurs between them. In extreme cases, the tonic phe- 
nomena are such in intensity and duration that the patient's life is at 
once sacrificed ; and, in those cases in which the fits succeed each other 
with great rapidity, the patient has, as it were, no time to regain her 
consciousness, and she remains in a condition of complete coma, which 
is only disturbed by the recurrence of the dreaded paroxysms, and 
which persists until the case terminates either in recovery or death. 

Pathology. — In considering the morbid conditions, and the laws 
which regulate the abnormal muscular action of puerperal eclampsia, we 
shall confine our 'observations almost exclusively to the true or ursemic 
variety, so admirably described by Braun. We have already admitted 
that chohemia, and the many varieties of toxaemia, may give rise to 
symptoms which are apparently identical with those of ursemic eclamp- 
sia. In like manner, epileptic patients may, during labor, or at any 
subsequent stage, be attacked with convulsive seizures, which the pre- 
vious history of the case, the occurrence of the "aura," and the ab- 
sence of albuminuria, will enable us, without difficulty, to discrimi- 
nate. Hysteria, too, may simulate many of the symptoms which have 
been detailed, but in this case also, the absence of albumen, — with a 
history of " globus," " clavus," or abundant urine, and an imperfect 
insensibility during the fits, — should prevent us from falling into 
serious error. But to enter upon the comparative pathology of all 



678 PUERPERAL ECLAMPSIA. [CHAP. 

these affections would lead us far beyond bounds, and we must there- 
fore content ourselves, by stating, as concisely as possible, what has 
been established or conjectured in regard to the ordinary or uraamic 
variety. 

That albuminuria and puerperal eclampsia are mutually dependent 
upon each other, or, at least, are of simultaneous occurrence in the vast 
majority of all cases, is an assertion not likely, in these days, to be se- 
riously controverted. But it is by no means agreed, as to the albumen 
and the paroxysm, which is the cause and which the effect. Accord- 
ing to Braun, and those who support his views, the albumen appears 
in the urine as the result of that inflammatory affection of the kidney 
commonly known as Bright's disease. As a result of this, the blood 
is poisoned with excrementitial elements of the urine, and especially 
with urea. The experiments and researches of Frerichs, alluded to in 
the previous chapter, have conclusively shown that the presence of 
urea in the blood, even in considerable quantity, does not give rise to 
eclampsia; and the conclusion which he has reached is, that the active 
poison is the carbonate of ammonia, produced, as he assumes, by the 
decomposition of the urea, which must, therefore, be acted upon by 
some particular ferment, the nature of which has yet to be discovered 
by the pathological chemist. Frerichs does not admit the essentially 
inflammatory nature of the disease; at least he appears to do so only 
to a limited extent, when he assumes, in explanation of the formation 
of the hyaline tube-casts, that the inflammatory theory can only hold 
good in so far as the exudation of blood-plasma is connected with a 
paralytic dilatation of the capillaries. Braun, however, broadly main- 
tains that the disease is of inflammatory origin, and that the nature 
of the morbid process is identical with that of Bright's disease. 

The other theory to which we have referred is that held by those 
who, while admitting the existence of albumen in the urine as an es- 
sential phenomenon, assert that this is the effect of eclampsia, and not 
its cause, — which is, by them, supposed to be the result of some blood 
disease, or of some blood poison, hitherto unknown to science. And 
certainly the fact that, in so many instances, the convulsions precede 
the abuminuria lends some confirmation to this view. 

We think that Braun is too absolute in his assertion that Bright's 
disease is the cause of puerperal eclampsia. He does not, indeed, deny 
the existence of the ansemic and other varieties already named, but he 
gives the latter so little prominence that one is apt to conclude from 
his description, — what, probably, he never intended, — that their im- 
portance is so little that they scarcely merit notice. No one, obviously, 
can take a clear and comprehensive view of the pathology of puerperal 
eclampsia, who does not freely admit that there are cases in which no 
ursemic poisoning exists. There is, however, we think, no impropriety, 
in the present state of our knowledge, in employing the term "true" 
as synonymous with " ursemic," in the nomenclature of puerperal 
eclampsia. But there is another point, in regard to which Braun seems 
to have carried his theory too far, or, at least, in regard to which he has 
failed to prove his case, — viz., that all cases of albuminuria are neces- 
sarily examples of true Bright's disease. Frerichs's idea on this point 



XLII.] PATHOLOGY. 679 

seems much more likely to be correct, for, if we do not misunderstand 
him, he appears to say that, although fibrinous exudation and albumi- 
nous urine indicate, undoubtedly, the first stage of Bright's disease, 
and in that case have an inflammatory origin, it by no means follows 
that the same symptoms cannot, by any possibility, proceed from other 
than inflammatory causes. 

When the uremic theory was advanced, it was assumed as possible 
that, in a large proportion of cases, albuminuria and the consequent 
succession of pathological changes w T ere due to pressure on the renal 
veins. This has been, to a certain extent, experimentally proved ; and, 
indeed, it seems to afford the only satisfactory explanation of the rapid 
disappearance of all symptoms of renal disturbance upon the delivery 
of the woman; an issue which we could not look for with equal confi- 
dence in any other case, unconnected with pregnancy, in which an ex- 
amination of the urine gave the same chemical and microscopical results. 
We do not for a moment mean it to be inferred that pressure on the 
renal veins can account for all cases. On the contrary, it is well known 
that the symptoms may, although very exceptionally, be developed, 
either early in the pregnancy, or after delivery, when such pressure as 
is implied is obviously impossible. But we do think that the subse- 
quent history of cases of puerperal eclampsia affords some ground for 
the supposition that the theory is worthy of more attention than Braun 
and Lever seem to have accorded to it. If, on the other hand, the dis- 
sections of Frankenhauser are to be held as demonstrating a direct con- 
nection with the nerves of the uterus, we must admit it as possible — 
as was indeed long before conjectured by Tyler Smith — that the nervous 
system and not the vascular system may after all be the starting-point 
of puerperal eclampsia. 

The presence of albumen in the urine is shown very clearly by the 
ordinary tests, of which the cold nitric acid test is one of the most deli- 
cate. By this method, a small portion of urine is placed in a test-tube, 
which, being held at an angle, while strong acid is slowly poured down 
the side, allows the acid to flow to the bottom. If albumen be present, 
and the experiment carefully performed, the contents of the tube then 
show three zones, — the upper, clear urine ; the lower, clear acid ; and 
the intermediate zone, where the two fluids have mingled, an opaque layer 
of coagulated albumen. It is unnecessary to detail the various falla- 
cies which are to be guarded against in testing for albumen, as these are 
now familiar to every clinical student. The observer should not forget 
that albumen is sometimes present intermittently, and that, therefore, 
a negative result by the tests is not conclusive evidence of a satisfactory 
discharge of the renal functions. The cylindrical tube-casts are most 
easily distinguished, according to Braun, if we examine the fresh urine, 
about an hour after it has been drawn off by the catheter, withdrawing, 
by means of a pipette, a few drops of the fluid from the bottom of the 
vessel. These casts are, however, it should be remembered, necessarily 
absent in alkaline urine, as they are dissolved in the carbonate of am- 
monia, which is the product of decomposition of the urea. Very elabo- 
rate descriptions are given by Frerichs of the different varieties of tube- 
casts, but such observations belong more strictly to the pathology of a 



680 PUERPERAL ECLAMPSIA. [CHAP. 

renal disease, than to the explanation of a puerperal disorder. We 
would direct attention here, further, to two important practical points 
to which Braun gives a prominent position; first, "The quantity of 
albumen has generally an intimate relation to the extent, intensity, and 
duration of acute Bright's disease, but not so constantly to the violence 
of the eclampsia;'' and, again, "The more acute the Bright's disease, 
the darker is the urine, and the more numerous, generally are the 
blood-corpuscles." 

Morbid anatomy throws no very new nor clear light upon the sub- 
ject. In fatal cases, which are necessarily the most severe, we would 
naturally expect to find evidence, more or less distinct, of Bright's dis- 
ease, in one or other of its stages or forms; but this cannot fairly be 
held as indicating with equal certainty, the pathology of those cases in 
which we venture to assume that the cause consists more in mechanical 
obstruction or peripheral irritation than in pathological lesion, and in 
which, presumably, a fatal result would be less likely to ensue. Proba- 
bly the result depends, then, in a great measure, upon the extent to 
which the structure of the kidney has become involved ; and if, in fatal 
cases, the hypersemic or exudative stage has rarely been observed, we 
may be sure that it is because these cases usually recover. If, on the 
other hand, the terminal stage, or stage of atrophy, has been reached, 
we cannot wonder that such irremediable disorganization should culmi- 
nate in a fatal result, with or without convulsions. Besides the morbid 
appearances which are characteristic of lesion of the kidneys, the only 
observations of importance which have been made are, that the lungs 
are constantly ©edematous and sometimes emphysematous — the result, 
as is assumed, of the straining of the fits. The spleen is almost always 
enlarged, but this should not be mentioned as characteristic of the dis- 
ease in question, as it is well known that enlargement of this organ 
is very usual, if not invariable, during pregnancy and the puerperal 
state, associated, probably, with some compensatory changes in the 
circulation. 

Some have supposed that uterine contractions have an important 
share in the etiology of eclampsia. That the disease may be mani- 
fested during pregnancy and after delivery shows clearly enough that 
this is not an essential condition, even although we may admit it as a 
possible cause. But, in truth, uterine action is much more likely to be 
the effect than the cause of eclampsia; for, if there be any truth in the 
theory — to which some prominence has been given in previous chap- 
ters of this work — that deficient aeration of the blood is a cause of ute- 
rine action, prematurely or at the full term, we can have no difficulty 
in admitting that this condition exists, during the paroxysm of eclamp- 
sia, in a high degree. "By exciting pains," says Braun, "and increas- 
ing their strength, fits cannot be produced at will, nor even aggravated. 
For w T e have made the observation that, under a high degree of reflex 
sensibility, convulsions cannot be induced at will, at definite periods, 
by violent irritation of the uterus." We do not doubt this assertion, 
that fits cannot be produced at will; but there are many cases on record 
of fits being produced, under such a degree of reflex sensibility as is 
here referred to, by attempts to introduce the hand into the uterus, 



XLII.] EFFECT OF LABOR PAINS. 681 

during labor, for the purpose of turning, or after labor, with the view 
of removing the placenta ; or, it may be, from emotional or other ex- 
ceptional causes. This may, no doubt, be assumed to be attributable 
to uterine sensitiveness ; but we are inclined to agree, for anatomical 
reasons, with Dr. Tyler Smith, that the irritation in such cases is more 
likely to spring from the vagina or the cervix uteri than from the 
nerves which are distributed to the body and fundus of the womb. On 
the whole, however, we must conclude that there is a very subordinate 
relation between uterine pains and ursemic eclampsia. 

The maternal and foetal mortality arising from this disease are sub- 
jects of great and obvious interest, since about thirty per cent, of 
mothers have hitherto succumbed to its effects, direct or indirect. A 
mortality so large as this must necessarily awaken in the mind an 
earnest desire for methods of treatment more effectual than any now at 
our command, and there can be little doubt, that, if the death-rate 
from this cause is in the future to be materially reduced, it must be by 
a careful and earnest investigation of pathological theories, and an ob- 
servation, dictated by the same spirit, of clinical facts. The life of the 
foetus is certainly to be looked upon, in every case of puerperal eclamp- 
sia, as in considerable danger. This fact being admitted, it is by no 
means agreed as to what is the cause upon which it depends. The 
stoppage of the circulation in the maternal vessels of the placenta, as 
suggested by Kiwisch, can hardly account for this; for, were it so, the 
danger would cease with the fit, whereas, the infant dies in about a half 
of all the cases, and almost always when the symptoms are severe and 
come on in rapid succession. There is good reason to believe that the 
actual cause of death in such cases is an extension of the toxic influ- 
ence from the blood of the mother to that of the child. On this point 
Braun observes, — " If, after numerous ursemic convulsive fits, the child 
is born alive, a large quantity of urea is found in the blood taken from 
the umbilical cord ; but if it is born dead, we can, immediately after 
the birth, demonstrate the presence of carbonate of ammonia in the 
foetal blood." 

It has been said that, next to rupture of the uterus, eclampsia is the 
most disastrous affection which it is possible for us to encounter in the 
practice of obstetrics. There are certain questions of prognosis, there- 
fore, in regard to which much anxious speculation must necessarily 
arise. The points, as already remarked, which chiefly call for anxiety, 
are an abundance of albumen (when the urine solidifies on boiling), 
violent fits with short intervals, and profound coma : the converse of 
these gives good hope of recovery. The dangers, however, of eclamp- 
sia depend, in no slight degree, upon the condition of the woman, and 
especially the period as regards pregnancy, labor, or childbed, at which 
the sv mptoms first manifest themselves. When eclampsia occurs during 
pregnancy, it is almost always during the last three months that the 
first attack takes place, the viability of the child being in most cases 
undoubted. It rarely happens in these cases — and then only when the 
symptoms are moderate — that pregnancy is permitted to go on to its 
natural term ; and this alone, irrespective of toxsemic action, is apt to 
compromise the life of the child. In one-fourth of the cases, according 



682 PUERPERAL ECLAMPSIA. [CHAP. 

to Braun, the albuminuria, or rather the ursemic or ammoniacal intox- 
ication of the blood/ is sufficient, without the occurrence of eclamp- 
sia, to induce premature labor; but, if the convulsive disorder should 
be developed, the chances of mature gestation and the life of the child 
are still further reduced. 

When rhythmical uterine contractions, and other symptoms, have 
indicated the commencement of labor before the manifestation of the 
convulsive phenomena, the effect which is produced upon that process 
is necessarily watched with much anxiety. In a certain number of 
cases, the obvious result is an acceleration in the progress of the labor, 
w T hen delivery is sometimes completed with great rapidity. " The 
process of labor," says Baudelocque, " in these cases, seems even more 
rapid then in others, as the child has often been found between the legs 
of the mother, although, an instant before, no disposition to delivery 
had been remarked." Inasmuch as no facts have hitherto been re- 
corded which prove that the muscular system of organic life partici- 
pates in the turbulent action of the muscles of animal life, it seems 
likely that the rapid expulsion in these instances is due rather to defi- 
cient resistance in the latter than to abnormal force of the former. It 
is quite possible, however, that the pains may, by a reflex action upon 
the nervous centres — surcharged, as Barnes supposes, by an excess of 
nervous force — excite the expulsive efforts to such an extent as to 
induce this result. But this is widely different, as will be observed, 
from a morbid supernumerary force arising from convulsive action. 
The result of delivery in effecting a diminution in the frequency and 
violence of the paroxysms is universally acknowledged, and is recog- 
nized in practice by the rule which is admitted to be of universal ap- 
plication, — to assist delivery as soon as the condition of the parts indi- 
cates that that stage has been reached when the passage of the child may 
be safely effected. 

It is a matter of dispute whether the eclampsia which develops itself 
for the first time after delivery, is, or is not, more dangerous than the 
other forms. Theoretically, one would think so, seeing that, uterine 
excitation and pressure on the renal veins being no longer in operation, 
the occurrence, under such circumstances, might be held as indicating 
a more grave constitutional affection. But Pajot, Blot, and others, 
have strongly deprecated this assumption, and have stated as the result 
of their experience, that in these cases, the issue is on the whole more 
satisfactory. In those instances in which fits have come on before 
delivery, the completion of labor, although it usually produces a marked 
amelioration of the symptoms, by no means places the woman out of 
danger. It has been observed by Blot that, putting aside the danger 
of repeated attacks of eclampsia, there is in such cases a special tendency 
to post-partum haemorrhage ; and others have noticed that there remains 
a proclivity to the various inflammatory affections to which a parturient 
woman is liable, such as uterine phlebitis, peritonitis, pelvic cellulitis, 
and the like, the occurrence of which is obviously favored by the de- 

1 Hammond and others have denied that the urea in the blood decomposes into 
carbonate of ammonia. 



XLTI.] TREATMENT. 683 

rangemcnts of the circulatory system which repeated attacks of eclampsia 
necessarily engender. 

Treatment. — The earliest stage at which the question of treatment 
may offer itself for our consideration, is when the symptoms during 
pregnancy are such as to cause serious apprehension of an impending 
explosion. The most important of these are albuminuria, tube-casts in 
the urine, and oedema. Although a complete cure of albuminuria is 
very rarely obtained during pregnancy, something may, no doubt, be 
done in the way of moderating the disease, and preventing its passing 
into its higher and more incurable grades. It is, at least, possible, by 
the administration of ferruginous tonics and by a liberal diet, as recom- 
mended by Cazeaux, to ameliorate a watery or otherwise deteriorated 
condition of the blood, and a good general effect is often produced by 
the use of tepid and vapor baths. In order to prevent decomposition 
of the urea in the blood, or to neutralize the carbonate of ammonia 
already formed, it was suggested by Frerichs that tartaric acid, benzoic 
acid, or lemon-juice should be regularly given, a recommendation which, 
although it has not yet received the assent of some eminent physicians, 
must be looked upon with interest as the necessary corollary to that 
author's proposition as to the pathogenesis of the disease. In every 
case, the function of the bowels should be carefully regulated, but 
purgation as a prophylactic measure, although strongly recommended 
by some, must be resorted to with caution, as there is a risk of thereby 
reducing the strength, which is already enfeebled. The quantity and 
microscopic conditions of the urine afford the best indications as to the 
necessity which exists for the use of diuretics. Braun recommends 
that, when exudation has taken place into the Malpighian capsules and 
the tubuli of Bellini and Fcrrein, the cylindrical clots must be removed 
from them, and the formation of new ones prevented. If the current 
of fluid proceeding from the vascular knot of the Malpighian bodies 
into the Malpighian capsules be strong, then the copious use of diluents 
is sometimes alone sufficient to wash away the cylindrical clots, and 
recovery ensues. But, if the secretion of urine be very scanty, and 
ursemic intoxication threatens to come on, then the force of the current 
proceeding from the Malpighian bodies must be increased, and the 
cylindrical clots removed, for which purpose the acids (above men- 
tioned), and the mineral waters of Selters and Vichy arc best adapted. 
According to the example of Frerichs, pills of tannin and extract of 
aloes may be used for restoring the normal tone. 

It has been proposed, with the view of obviating eclampsia and its 
dangers, that premature labor should be induced. Tarnier recommends 
that this should be done before the symptoms become urgent ; but we 
think that Braun's view is decidedly more judicious, when he insists 
that labor should only be provoked when the symptoms are such that 
the life of the woman is in danger. When the child is already dead, 
Ave are, of course, more justified in having recourse to this measure. 
When labor comes on without eclampsia, it has been recommended by 
Chailly that chloroform be employed, with the view of warding off the 
attack. 

In the treatment of eclampsia, in which the explosion has already 



684 PUERPERAL ECLAMPSIA. [CHAP. 

taken place, our mode of procedure must necessarily differ, according 
to the period — pregnancy, labor, or childbed — at which the fits develop 
themselves. But, as regards the treatment during the paroxysm, the 
indications are the same in all cases, and consist mainly in doing what 
we can so to act upon the nervous system as to moderate central irrita- 
bility, and reduce peripheral or reflex excitability to a minimum. It 
is but a few years since all cases of eclampsia, with the exception of 
the ansemic and hysterical varieties, were treated upon one and the 
same principle — that being free general bloodletting. The facts, how- 
ever, which modern pathology has disclosed have completely altered 
the plan of treatment. Perhaps, in some quarters, the rejection of the 
lancet has been too absolute. Indeed, we incline strongly to this belief; 
for there are cases, in which the constitution and temperament of the 
woman, and the violence of the attack, along with evidence of vascular 
tension of the brain, quite warrant us in supposing that venesection 
would afford the best chance of recovery. Still, it must be confessed 
that indiscriminate bleeding was a monstrous error, and that it would 
be better to do nothing at all than to bleed without selection of cases. 
Those who, in the present state of professional opinion, shrink most 
from the idea of the lancet, may at least, in suitable cases, apply 
leeches freely to the temples. 

A remarkable effect is produced, in many cases of puerperal eclampsia, 
by the administration of chloroform, ether, and other anaesthetic agents; 
an effect which, in some instances, quite surpasses our expectations. 
The approach of a repeated paroxysm, or symptoms such as make us 
dread the commencement of a first seizure, are a sufficient warrant to 
adopt this method of treatment. Respiration being much impeded, as 
we have seen, during the fit, it is proper at that time to withhold the 
chloroform, so as not in any way to interfere with the function of 
respiration while the aeration of the blood is already so seriously in- 
terrupted. Anaesthesia, however, often has the effect of holding in 
subjection the premonitory symptoms, and so long as this result is 
undoubted, we may keep up the effect until the patient falls asleep, or 
the approach of stertor shows that the action of the drug can be safely 
pushed no further. When chloroform — which is the agent usually 
employed — fails to avert convulsions, it has very generally the effect 
of modifying them ; and we may infer that, by its action on the muscles 
of the mouth, throat, and larynx, the danger of suffocation, during the 
period of tonic spasm, is materially diminished. And there can be 
no doubt, as Barker observes, that chloroform alone has considerably 
diminished the rate of mortality in these painful eases. 

The hydrate of chloral is another anaesthetic agent, which has of late 
been strongly recommended. The sedative and narcotic effects of this 
drug are well known, but it is not so generally understood that when 
it is pushed further, it produces an anaesthetic effect, under the influence 
of which a woman may be delivered without experiencing the slightest 
suffering. We can, without hesitation, corroborate much of what has 
been advanced of late in regard to the marvellous effects of this drug 
in the treatment of convulsive diseases. When given in what we may 
call ordinary sedative doses — not more than thirty grains — its effect is 



XLII.] ANAESTHETICS. 685 

safe, and in most cases efficacious ; but, should we think of giving larger 
and repeated doses, we must bear in mind, that very alarming symp- 
toms are occasionally produced, and that death has even been the result 
of what we might consider quite an ordinary dose. A number of cases 
have been of late recorded in proof of the efficacy of chloral in eclampsia. 
We extract the following from the Gazette des Hopitaux of Feb. 22, 
1873 : " A woman of twenty-one, pregnant for the first time, who had 
suffered for fifteen days from oedema of the lower limbs and of the 
eyelids, from headache, somnolence, great weakness, and frequent calls 
to urinate, was admitted to the hospital of La Charity, under the care 
of M. Bourdon. On her admission, a large quantity of albumen was 
discovered in the urine. Three days passed without any appreciable 
change in her condition ; but, on the fourth day, a violent attack of 
eclampsia took place, which lasted for ten minutes. During the period 
of resolution, an enema containing four grammes (a little more than 
one drachm) of hydrate of chloral was administered, after which the 
patient almost immediately fell asleep. At the visit on the following 
morning labor had not commenced. Foreseeing the probability of a 
renewed attack, M. Bourdon had two injections prepared, each con- 
taining four grammes of chloral. The first was administered at ten 
o'clock in the morning, just as labor had commenced. The second 
was given two hours afterwards. At three o'clock the labor terminated, 
without the woman having experienced the slightest pain. On the 
evening of the birth, a second eclamptic attack took place. A draught 
containing four grammes of chloral was at once administered ; she had 
a quiet night, and no fresh attack took place ; the oedema rapidly dis- 
appeared, and the patient left the hospital fifteen days afterwards." 

The effects of chloral are further illustrated in a remarkable thesis 
by M. Charpentier, 1 in which he contrasts the effects of the various 
remedial agents which, up to this time, have been employed in the 
treatment of eclampsia. He, more particularly, compares the effect 
of treatment by the old method of bleeding, and the modern plan of 
anaesthesia, with the following striking result, which we quote, how- 
ever, with the reservation applicable to obstetrical statistics in general : 

Mortality in cases treated by bleeding, . . .35 percent. 
" " " anaesthetics, . .11 " 

We must carefully avoid, moreover, the danger of adopting any par- 
ticular method of treatment to the exclusion of others. If we admit 
that throbbing carotids, and marked suffusion of the eyes and face after 
the subsidence of the fits, are exceptional symptoms, warranting blood- 
letting, we may, in like manner, concede that ice to the head may, in 
similar cases, be beneficial. Dashing the face and surface with cold 
water during the fit, as recommended by some, is always to be avoided; 
for it is quite obvious that an excitation of this kind is likely to be 
followed by reflex convulsive phenomena. Sponging with warm water, 
or tepid vinegar and water, has been found useful; and opium, in some 
form or other, has often been freely administered, both by the mouth 

1 De l'influence de divers traitements sur les acces eclamptiques. Paris, 1873. 



686 PUERPERAL ECLAMPSIA. [CHAP. 

and by enema, in eases in which the other methods of treatment have 
not operated with sufficient rapidity. 

What may be called the obstetrical treatment of eclampsia involves a 
more particular reference to the stage at which the seizure occurs. The 
cases in which we would be justified in inducing premature labor are 
very exceptional; for it must be remembered that the usual effect 
of eclampsia is to bring on labor, so that we need not Interfere in the 
process. Still, there certainly are eases where the gravity of the symp- 
toms may call for prompt and decisive action. 

In eclampsia occurring during labor, our mode of procedure must, 
of necessity, be regulated entirely by the stage of the process which has 
been reached. There are, however, two preliminary points which it is 
necessary to have in view throughout: 1st, that on account of the 
extreme irritability of the nervous centres, we should avoid, as far as 
possible, all sources of reflex irritation, and, above all, any unnecessary 
manipulation or digital examination; and, 2d, that although we recog- 
nize the importance of speedy delivery, we must be extremely careful, 
in adopting operative means for accelerating the process, to choose, if 
it be practicable, those only which are least likely to excite increased 
muscular action, whether of the voluntary or involuntary muscles. If 
the os is still closed and rigid, Ave content ourselves with cold applica- 
tions to the head, and at the same time, by means of chloroform or 
chloral, attempt to allay the nervous irritability, while we await the 
result of the natural process of cervical dilatation. If we wish to bring 
on labor, the safest method of provocation is to introduce an clastic 
catheter, in the manner described in a previous chapter. 

When the os is already partially dilated and dilatable, the treatment 
which is now recommended by almost all the best authorities, is to 
rupture the membranes, and, after thus permitting the escape of the 
waters, narrowly to observe the subsequent stages of the process. For- 
cible dilatation of the os (accouchement forcie) is a method of procedure 
which can scarcely he admitted as warrantable under any circumstances, 
and the same observation applies to the incision of the soft parts after 
the method recommended by Baudelocque. When the os is dilated, 
and the stage, consequently, has arrived at which the forceps may 
easily be applied, we hold the blades in readiness for immediate use ; 
but, even here, if the parts are anatomically in a favorable condition, 
it is better to leave the case for a time to nature 1 . When the head has 
passed downwards in the pelvis, and is pressing on the perineum, we 
need have little hesitation in using the instrument, should tin; condi- 
tion seem urgent, or the labor begin to flag. The operations of tinning, 
or of craniotomy, should never be entertained, unless in the presence of 
malpresentation or pelvic disproportion, when the rules applicable to 
these complications must be observed. Ai'ivv delivery, if is advisable 
that the removal of the placenta should not be long delayed, and (he 
accoucheur should pay particular attention to the contraction of the 
uterus and the removal of clots. 

Should the convulsions persist after delivery, or should they then 
come on for the first time, full doses of opium or chloral, the adminis- 
tration of chloroform, cold to the head, perfect rest and quiet, and the 



XLIII.] PUERPERAL FEVER. 687 

emptying of the bowels, if necessary, by a simple enema, are the main 
points to be attended to. It is very unlikely that at this stage bleeding 
would be held to be advisable, but it is possible that some benefit might 
be derived from ligature of the limbs, by which a large quantity of 
blood — thirty ounces, according to Vogel — may be temporarily with- 
drawn from the circulation; but this is a process in regard to which 
we must learn more before we can be confident as to its results. When 
the convulsions present the eharacter of hysteria, or are of the so-called 
anaemic variety, the treatment must, of course, be modified, in the one 
case, by the addition of the familiar antispasmodic remedies, and, in the 
other, by the administration of stimulants, with, subsequently, generous 
diet and tonic restoratives. 



CHAPTEE XLIII. 

PUERPERAL FEVER AND ALLIED AFFECTIONS. 

PERPLKXING NATURE OF THE SUBJECT— PUERPERAL FEVER: DOES A SPECIFIC 
PI ERPKRAL POISON REALLY EXIST ? — SHOULD THE TERM " PUERPERAL FEVER " 
BE RETAINED? — METRIA — PHYSIOLOGICAL PECULIARITIES OF THE PUERPERAL 
STATE— PUERPERAL SEPTICEMIA — MODE OF SEPTIC POISONING— CON N ECTION 
WITH CERTAIN ZYMOTIC INFLUENCES: ERYSIPELAS, SMALL-POX, SCARLET 
FEVER, ETC—CONNECTION WITH POST-PARTUM INFLAMMATIONS— PUERPERAL 
PERITONITIS; MAY EXIST INDEPENDENTLY OF PUERPERAL FEVER: SYMPTOMS 
OF AN ORDINARY ATTACK ; OF TH E MORE SEVERE FORM — FALSE PERITONITIS — 
PUERPERAL METRITIS ; OK LESS FREQUENT OCCURRENCE : SYMPTOMS — UTERINE 
PHLEBITIS: SYMPTOMS AT FIRST OBSCURE: SECONDARY ABSCESSES IN THE 
LATER STAGE: TISSUES CHIEFLY INVOLVED — VAGINITIS; STHENIC AND AS- 
THENIC — INFLAMMATION OF THE UTERINE LYMPHATICS. 

There is, perhaps, in the whole range of obstetrics, no subject 
which the writer and teacher approaches with so profound a convic- 
tion of difficulties to be encountered, as that group of affections of the 
puerperal perio'd to which the term Puerperal Fever has, witli a some- 
what loose signification, been given. Beyond what he has learned 
from personal experience, he naturally turns to the literature of the 
subject, in the expectation that, by an analysis of the opinions expressed 
by the best authorities, he may succeed in formulating an intelligible 
nosological classification, reliable pathological data, and clear views of 
treatment. A very short experience will suffice to dissipate this delu- 
sion, so that he will soon recognize the difficulties of his position. It 
must be confessed, however, that the general tendency of the most 
recent contributions to this department of our literature has been to 
clear away many of the prejudices and errors of the past. That per- 
plexities still remain is matter which can cause us no surprise, and we 



688 PUERPERAL FEVER. [CHAP. 

may be well content if we can recognize in the views of the present day 
theories which are more intelligible, more consistent with personal ex- 
perience, and which point significantly to a solution of many problems 
which have vexed successive generations of able writers and expe- 
rienced practitioners. 

When we employ the term "puerperal fever" in the singular num- 
ber, the expression may be held to imply a belief in the existence of a 
specific fever which runs a definite course to a crisis, after a period of 
latency, and is due to what we call a specific poison, in the same sense 
as we have a typhous, an enteric, and a variolous poison. This puer- 
peral poison was commonly assumed to be developed only in the puer- 
peral state, and communicable only from one puerperal woman to 
another. The first question to be determined then is — does any such 
specific poison exist? or, in cognate terms — does any such disease occur 
as specific puerperal fever? 

To these questions we do not hesitate to give a negative reply ; and 
indeed we confess to the existence of an impression that the term " puer- 
peral fever" might be discarded, to the ultimate advantage of all con- 
cerned. The expression " post-partum fevers" has been suggested, and 
is in some ways to be preferred ; but, in the present and still unsettled 
state of the subject, it would, we believe, be dangerous to abolish old 
familiar landmarks, and on that account, we are content to retain it, 
employing it, as it were, under protest, and in a guarded or limited 
sense. One might have less hesitation in retaining the name, had it 
anything even approaching to a definite signification, but the fact that 
ideas the most conflicting have been, and are entertained on this sub- 
ject, is the chief reason of the perplexity and obscurity in which the 
whole subject is involved. 

If proof of this were desired, all that is necessary is to read the ac- 
counts given of various epidemics, and of the experience of those whose 
high reputation and recognized power of observation are the most per- 
fect guarantee of their good faith. Each depicts a febrile disease of the 
puerperal period ; but the symptoms, far from harmonizing, present 
the most startling contrasts. Are we then painfully to collate such 
facts, and by describing a multiplicity of varieties, draw attention to 
points of contrast more than to features of resemblance ? Or, again, 
we find one author asserting that, under the most heroic use of the 
lancet, almost all his cases recovered ; a second has observed that, when 
bloodletting was practiced, almost every case died ; while a third 
describes, under the name of puerperal fever, an affection so trifling 
that it was usually checked by a single close of Dover's powder. Are 
these cases really of the same nature, — we ask in excusable bewilder- 
ment, — or are they the same in name only? It were easy to multiply 
questions of this kind, which meet us on every hand, as we follow the 
narratives of recorded facts; but enough has been advanced to show 
with sufficient clearness the perplexing nature of the subject which we 
have now reached. 

The more carefully one examines the whole matter, more especially 
if with a desire to secure a comprehensive grasp of the subject, the more 
apparent does it become that it is necessary to group together, under 



XLIII.] IS IT SPECIFIC? 689 

one head or generic designation, the greater number of the inflamma- 
tory and febrile affections of the puerperal state. It was this feeling, 
we presume, which led to the adoption by the Registrar-General of the 
term " Metria/' under which head that functionary ranges all cases of 
death from the acute affections of the puerperal state. After due con- 
sideration, however, we have grouped all these affections together under 
the title which has been adopted for this chapter, so that the inflam- 
matory affections of the puerperal state may be considered along with 
the so-called puerperal fever. Not that it is doubted that peritonitis 
and metritis may exist as simple inflammations, but because it is uni- 
versally admitted that these affections are among the most frequent 
concomitants of the more fatal cases of the childbed fevers, evidence, 
indeed, of the existence of the former having been found by M. Tonnelle 
in no less than 193 out of 222 dissections. While, therefore, we shall 
consider these inflammatory affections apart, we desire not to lose sight 
of their important affinities, both pathological and practical. It was 
no doubt a consideration of these facts which led some of the most 
eminent American practitioners, and the French school generally, to 
adopt the conclusion that puerperal fever is primarily a local inflam- 
mation. They differed much as to their ideas in regard to the tissues 
actually involved, the greater number, perhaps, maintaining that phle- 
bitis in some form was the initiatory inflammatory phenomenon ; and 
some have gone so far as to imply their disbelief in the possibility of 
the local inflammations existing apart from what they call true puer- 
peral fever. 

But, in rejecting the theory, long held in common with many others, 
that there exists a specific puerperal poison, we are bound to state, as 
clearly as the difficulty of dealing with a still obscure subject will 
permit, what views we propose to substitute for those discarded. 
Nothing, we think, is clearer than that writers have, under the head 
of puerperal fever, described a number of quite different affections ; 
and if we attempt arbitrarily to state what of these are, and what are 
not the true fever, we will only contribute to the chaotic confusion in 
which the whole subject is involved. But, if we take a bolder and 
more comprehensive grasp of the subject, and admit that the symptoms 
which we call puerperal fever may arise from a number of different 
poisons or causes, and that the apparently specific character of the dis- 
ease is due, not. to anything specific in the cause, but to the peculiar 
physiological condition under which a puerperal woman lies, then we 
shall see some ray of light through the clouds. And, although, from 
this point of view, we cannot expect that all our difficulties shall dis- 
appear, we shall find that the prospect brightens, and we look, for the 
first time with confidence, to a period when the mists shall still further 
be cleared away, and enlightened pathological views may point the w T ay 
to more successful treatment, and a saving of human life. 

Of all the modes in which fever may be generated in a puerperal 
woman, that by means of septic absorption, for which her condition at 
the moment offers peculiar facilities, is, we now believe, decidedly the 
most frequent, although it is only of late years that it has come promi- 
nently into notice. Some go so far as to say that to these cases alone 

44 



690 PUERPERAL FEVER. [CHAP. 

should the term puerperal fever be given. "Under the term puerperal 
fever," says Schroeder, "we plaee all such diseases of puerperal women 
as are caused by the absorption of septic matter, that is, organic sub- 
stances in the process of decomposition." If Ave could accept this view 
without reserve, the whole subject would become simplicity itself; but 
until certain facts connected with the germ theory of disease, and the 
presence and diffusion of bacteria in septic matter are cleared up, it 
would be premature to close the question. Matthews Duncan, who 
agrees with Schroeder, prefers the term of puerperal pyaemia ; but 
whether the word employed be septicaemia, pyaemia, or ichorrhaemia, 
the essential points are — a wound capable of absorbing, and a poison 
which is there absorbed. 

The idea of septic absorption by the surface from which the placenta 
has been removed is no new one. The theory of the present day is not, 
however, founded upon a mere surgical speculation, but has its basis in 
a series of brilliant investigations, including the demonstration of phle- 
bitis and lymphangitis, of thrombosis and embolism by Virchow, and 
the well-known researches of Lister in regard to the action of septic 
poisons generally, and the influence produced by the development of 
bacteria. It is now known that poison introduced in this way does 
not generally act at the site of the placenta, but through the slight 
lacerations which occur in the tissues of the cervix, or through wounds 
which are the result of tearing of the fourchette, or fissures in any part 
of the vulvo-vaginal canal. 

The septic material may be introduced by the finger, by infected 
sponges or dressings, possibly through the atmosphere; and, in a 
limited number of cases, where unhealthy action has taken place in the 
wounds, absorption takes place of decomposing maternal parts by the 
surrounding living tissues. But, while we believe that this affords by 
far the most satisfactory solution of the question in regard to most 
cases, it seems to us equally clear that a fever, apparently identical in 
its symptoms and course, may arise from other poisons and other causes. 
Erysipelas is one of the most apparent of these, so much so, indeed, that 
they who believe in the existence of a specific poison have even sur- 
mised that the two poisons were identical, a conclusion which is not 
altogether inconsistent with the septicaemic theory. 

It is manifest that women, during the puerperal period, may be so 
circumstanced as to come within the range of the poison of any of the 
specific eruptive fevers. The result of the contagious influence is fever. 
Take the most familiar illustration, scarlatina; and, we ask — Is this 
fever scarlatina pure and simple; or is it what we call puerperal fever, 
modified more or less by the action of the specific poison? That this 
is at the present moment a point of special significance, is clearly indi- 
cated by the interesting debate which, while these pages are passing 
through the press, continues to occupy the attention of the Obstetrical 
Society. The manner in which this discussion has been conducted, by 
encouraging expressions of opinion from practical men, quite as much 
as by inviting theoretical speculations, seems to warrant the belief that 
this newly awakened interest will not be barren of results. In regard' 
to the question which we have proposed, the balance of opinion was in 



XLIII.] SEPTICEMIA. 691 

favor of the view to which we adhere, — that although the poison of 
scarlatina may produce in puerperal women scarlatina and nothing 
more, this is not the rule, but a rare exception. What we are apt to 
overlook in discussing this whole subject, is the peculiar condition of 
the woman, no less in the condition of her blood, than in the newly 
organized function of lactation and uterine involution. Need we won- 
der then, that, when a woman so placed is attacked with scarlatina, these 
facts should derange the action of a special poison, and give to the dis- 
ease which is engendered more or less of the features of what — still 
under protest — we call puerperal fever. It matters little in practice 
whether we say that it is modified scarlatina, or modified puerperal fever, 
so long as we recognize the affinity which subsists between the two. 

In precisely the same manner the other eruptive fevers may induce 
an affection which, whether it retains more or less of the specific char- 
acteristics of the disease from which it has been engendered, usually 
gives clear evidence of the puerperal type of febrile disease. Variola 
and typhus may thus take their course, but the puerperal state fearfully 
augments the risk ; and we have lately seen an extremely painful case 
in which a case of undoubted enteric fever, occurring in the puerperal 
period, passed into a condition which it was impossible to distinguish 
from the more familiar septicemic variety. 

There is another class of cases in which the earliest symptoms are 
clearly inflammatory. In these, the symptoms and course of the malady 
present, as a rule, points of contrast with puerperal fever which are very 
striking. Be it well understood that we do not speak now of inflam- 
mations which arise in the course of the more common variety of the 
fever. These we may, without hesitation, refer to the adjacent septic 
action. But when the patient, by exposure to cold or imprudence of 
any sort, becomes affected with an inflammation which attacks the tis- 
sues of the peritoneum, the womb, or the neighboring structures, the 
inflammation, thus or otherwise engendered, sometimes runs to a fatal 
result, giving rise the while to symptoms which, if not identical with, 
it would be injudicious to separate from those of puerperal fever. 

An adherence to the term " puerperal fever," or the limiting of that 
designation to any particular class of post-partum disorders, may then 
be considered as points of deep interest, but, comparatively, of little 
practical importance. This we shall endeavor, in the sequel, to prove. 
The importance of precision in nomenclature is a point which can scarcely 
be overestimated, but in the present divided state of opinion it is ob- 
viously unattainable, however much to be desiderated. Precision, as 
we now stand, means dogmatism ; and although it is much easier to be 
dogmatic than to be judicial, the only attitude which is justified by the 
science of the present day is one which, while it permits us to express 
our individual opinion and experience, debars us from pinning our faith 
to any theory of which subsequent research may demonstrate the error. 
Should the day arrive when all are willing to read " puerperal septicae- 
mia," for " puerperal fever," we shall willingly give in our adhesion, 
but in the meantime we prefer to term it a puerperal fever. 

Under the designation of " allied affections," it is well that we should 
consider at this place those local inflammatory affections, which although 



692 PUERPERAL FEVER. [CHAP. 

in their simple form not entitled to rank as fevers, are, as we have said, 
apt to run into a peculiar and fatal febrile condition. In their simple 
form, or early state, we prefer to call them "post-partum inflammations." 

[We would have been glad if the author had been bold enough to 
have abandoned the term "puerperal fever" entirely. This would 
certainly be more in accordance with the tendency of modern thought, 
though such a course is strongly opposed by many high authorities, 
among whom Prof. Fordyce Barker, of New York, occupies a promi- 
nent position. This gentleman, in the recent discussion on this subject 
before the Obstetrical Society of London, has thus tersely stated the 
question at issue : " The gist of the matter, stripped of its superfluous 
and obscuring elements, lies in the inquiry whether there be a disease 
which attacks puerperal women, and only puerperal women." We 
believe that the careful study of the diseases of childbed women which 
have long been described under the name of puerperal fever, will decide 
this question in the negative. The truth can only be reached by study- 
ing this subject in its broadest sense. Conclusions cannot be justly 
drawn from the study of a single series of cases, or from observations 
made during any one period of an outbreak of one of these diseases. 
All of the phenomena of the various puerperal disorders of this class 
must be separately investigated, and their value carefully estimated 
before' correct conclusions can be reached. The great source of diffi- 
culty appears to be the fact that affections of the most diverse nature 
may lead to the production of the same symptoms, and that these have 
their origin in the same causes. This expression is used advisedly, 
and its meaning will become apparent in the sequel. 

That the author is correct in his view that precision is unattainable 
in the present state of our knowledge cannot be denied. Any classifi- 
cation of these diseases made at the present time must be open to 
criticism and subject to important modification with the increase of our 
information upon these subjects. But differences in nomenclature have 
long impeded the march of our knowledge of the puerperal diseases, 
and at the risk of his " precision " being styled "dogmatism," the editor 
ventures to suggest the following classification of the affections usually 
described under the name of puerperal fever. We believe that they 
may be divided into three classes : 

I. Local inflammatory diseases : 

a. Metritis. 

b. Pelvic cellulitis. 

c. Pelvic peritonitis. 

d. General peritonitis. 

II. Septic diseases : 

a. Pysemia and septicaemia. 

b. Diphtheria of wounds. 

o. Erysipelas of the genitals and internal organs. 

III. Idiopathic fevers in the puerperal female. 1 

1 This classification is a slight modification of that published by the editor in a 
paper entitled a " Description of a form of Puerperal Fever which occurred at tho 



XLIII.] SEPTICAEMIA. 693 

In the first of these classes vaginitis, which is described by the 
author, might have been included. Phlebitis and angeioleucitis are 
not mentioned, because, although we have met with these many times, 
we have never known them to be primary in their origin. In all cases 
in which they have come under our notice, they have been the result of 
septic or purulent infection. 

Metritis appears to be rare as a primary disease. In a large majority 
of cases it results from the absorption of some morbific matter which 
produces one of the septic diseases which are usually described as 
" puerperal fever." 

The great difficulty which has prevented the classification of the 
various affections which have been described under this one name is 
that all of them may be attended with, or produce the symptoms of 
purulent or septic infection. 

Any one of the first class, though at its commencement a simple 
inflammatory disease, may produce pyaemia or septicaemia. This has 
led to their being confounded with the latter diseases when primary 
in their origin. One of the most common effects of septic or purulent 
infection in the puerperal woman is peritonitis, but under these cir- 
cumstances the serous inflammation is of a different nature, has a 
different origin, and runs a totally different course from that form of 
general peritonitis which sometimes follows labor, and which apparently 
results from exposure or the extension of a traumatic inflammation. 
The latter is a sthenic, the former an asthenic disease. The latter 
always begins in the hypogastric region and extends upwards. The 
former being due to the altered condition of the blood as well as to 
extension of inflammation from continuity of tissue may begin in that 
part of the peritoneum which is most remote from the uterus and its 
appendages. We have a number of times seen the evidences of inflam- 
mation confined to the peritoneum covering the diaphragm, liver, 
spleen, and stomach, in these cases. Bloodletting promptly destroys 
the victims of pyaemic peritonitis. It as certainly saves life in sthenic 
inflammation of that membrane if resorted to during the first few hours 
after the commencement of the disease. 

But acute general peritonitis, however high the reaction may be in 
the first instance, may be followed by exhaustion of the vital powers, 
when the products of inflammation or suppuration may be absorbed, 
and contaminating the blood, lead to septicaemia or pyaemia, which is 
generally described as " puerperal fever." 

Precisely the same remarks apply to pelvic cellulitis and pelvic 
peritonitis. Either may be a primary disease, or it may be secondary, 
the result of the absorption of some animal poison. In the first case 
they begin as local inflammations, and are to be treated as such. They 
may end in resolution or suppuration, and under the latter circum- 
stances result in purulent absorption and the production of pyaemia, 
which has led to their being denominated " puerperal fever." 

One great source of difficulty in the study of these diseases has arisen 

Philadelphia Hospital, characterized by diphtheritic deposits on wounds of the geni- 
tal passages, and other peculiar phenomena." American Journal of the Medical 
Sciences, January, 1875, p. 46. 



694 PUERPERAL FEVER. [CHAP. 

from the belief which has been entertained by some of the best obstet- 
rical authorities who have ever lived, that the poisons of the idiopathic 
fevers are convertible into that of a distinct disease peculiar to the 
lying-in woman, and which was called "puerperal fever." This ques- 
tion demands a careful examination. The editor has had opportunities 
to observe a large number of cases of puerperal diseases during the past 
ten years. He has also seen a number of women who were attacked 
with one of the essential fevers during the puerperal period. He has 
never made any observations which would lead to the conclusion that 
the poison which produces scarlet, relapsing, or typhus fevers, or any 
other diseases of their class is convertible into a materies morbi, which 
Avhen taken into the system of a puerperal woman is capable of produc- 
ing a disease peculiar to the puerperal female, and which is capable of 
being indefinitely propagated by contagion or inoculation among other 
lying-in women. It is to be remembered that allusion is here made 
to a specific disease peculiar to the puerperal period, one which does 
not occur under any other circumstances. This is important, for it 
cannot for one moment be denied that under these circumstances a 
disease is generated which is entirely different from the essential fever 
in which it originated and which is capable of being transmitted from 
one puerperal woman to another, through the atmosphere and on the 
hands or clothing of the accoucheur. 

Notwithstanding what has been said, there is reason to believe that 
the poisons of scarlet fever, variola, and other diseases of their class 
produce primarily the same effects upon the puerperal woman that they 
do upon her non-puerperal sister. Under the former circumstances, 
however, the course of the disease is modified by the puerperal state. 
Women who have been recently delivered are peculiarly susceptible to 
the influence of purulent and septic absorption. This fact is so gen- 
erally admitted that it does not need demonstration. In this state the 
pelvic tissues, the vagina, cervix uteri, and pelvic areolar tissue are 
more or less injured and bruised as the result of labor. Under ordi- 
nary circumstances the puerperal period is passed, and these parts are 
restored to their normal condition without giving rise to any abnormal 
symptoms. If the woman is attacked by typhus, scarlet, or typhoid 
fever, the case is totally different. The vitality of these tissues is im- 
paired by the injuries sustained during labor, while their nutrition is 
now interfered with by the blood changes induced by the zymotic dis- 
ease which has attacked the woman. The result is that these bruised 
tissues undergo inflammation, the absorption of the products of which 
still further impairs the condition of the blood, and leads to the pro- 
duction of pyaemia or septicaemia. The symptoms of local inflamma- 
tory action and purulent or septic contamination of the blood may be 
-so severe as to entirely overshadow the original disease and the one 
which induced them. Pyaemia or septicaemia thus produced does not 
differ in its nature from the same affections in non-puerperal females 
and in males. 

Erysipelas contracted under the same circumstances runs a somewhat 
modified course. It is terribly fatal when it attacks the wounded geni- 
tal organs of a newly delivered woman. It produces death directly, 



XLIII.] PERITONITIS. 695 

or the fatal termination may be due to pyaemia or septicaemia in which 
the erysipelas may result. — P.] 

Peritonitis — Puerperal Peritonitis. — This, as one of the most frequent 
inflammatory sequelae of delivery and the most familiar accompaniment 
of puerperal fever, is the affection which naturally is the first to attract 
our attention. Inflammation of the peritoneum may, as we have said, 
exist and run its course without any manifestation of symptoms indi- 
cating the operation of a morbid poison ; in other words, puerperal 
peritonitis may exist as an affection distinct from puerperal fever. In 
some cases it affects a small portion only of the membrane in the pelvic 
region ; when it may give rise to a more chronic affection (Pelvi-peri- 
tonitis), which will fall to be considered in a subsequent chapter. 

An ordinary attack of peritonitis almost always comes on within a 
week of the period of delivery. The patient is seized with a rigor, of 
greater or less severity, followed by heat of skin, acceleration of the 
pulse, and other febrile symptoms. At the same time, she complains 
of pain in one spot — usually in the pelvic region — whence, if violent in 
degree and unchecked, it may pass over the whole of the abdomen. 
Imprudence during the period of convalescence may no doubt lead to 
the development of simple peritonitis, but this is less frequently the 
case than we might have anticipated. The sooner after labor the 
symptoms are manifested, the more serious is our prognosis as to the 
issue of the case; and, in a large proportion of cases, if not checked by 
appropriate treatment, it is apt to run rapidly to a fatal termination. 
That portion of the abdomen which is the seat of the inflammation has 
often been observed to be swollen and tumid. The pulse is quick, 
wiry, and incompressible, and rises in frequency as the inflammation 
extends; the tongue is not usually much altered in the early stage. 
Nausea and vomiting are of frequent occurrence as the disease pro- 
gresses, and the swelling and tumefaction of the belly become more 
marked. The bowels are obstinately costive, and, in the more advanced 
stages, the patient lies on her back with her knees drawn up. 

To this, if the symptoms are unchecked, succeeds a second stage, 
which it is sometimes impossible to distinguish from one of the more 
familiar forms of puerperal fever. There is now a decided change in 
the character of the symptoms. The pulse, although it loses nothing 
of its rapidity, and may even become more rapid, changes in character 
from the inflammatory to the asthenic type. There is a marked altera- 
tion in the countenance, a pitiful appearance of ghastly distress. The 
belly swells still further and becomes tense, with great aggravation 
of the suffering, so that the patient can now no longer bear even the 
pressure of the bedclothes. If the lochial discharge has not been pre- 
viously arrested, it now becomes fetid, and the breasts become flaccid. 
The tongue is dry and often furred, and the unhappy patient suffers 
from excessive thirst. The violence of the vomiting in some degree 
subsides, but the patient is now attacked with diarrhoea, which is often 
violent and uncontrollable. The extremities become cold ; the surface 
of the body is bedewed with a clammy .perspiration ; and low mutter- 
ing delirium sets in. With these symptoms, or even at an earlier 
period, there is a remission or cessation of the pain, which sometimes 



696 PUERPERAL FEVER. [CHAP. 

gives rise to fallacious hopes in: the mind of the patient and her friends. 
Hiccough, picking of the bedclothes, and delirium are the immediate 
precursors of death. Occasionally, a rapid metastasis of the inflam- 
mation takes place, even after an abatement of the symptoms has led 
us to hope that the danger had passed. The inflammatory process may 
thus blaze out afresh and with equal violence — in the pleura, for ex- 
ample — and we have known a second metastasis take place, first to one 
pleura, and subsequently to the other. 

When a case goes on to this more advanced stage, it is difficult to 
say, with any approach to certainty, whether it is to be regarded as, 
from the first, an example of puerperal fever. Whether it be so or not 
seems a matter of very secondary importance, if, in the end, the symp- 
toms of the two are identical. Nor is it of any great moment to deter- 
mine where the one variety ends and the other begins. If we admit 
the fact, that the puerperal poison may be generated from various 
sources, may we not assume it as probable — to say the least — that it 
may be developed in the course of an inflammatory disorder, which is 
so frequently its accompaniment? 

When peritonitis occurs as a complication of puerperal fever, which 
constitutes one of the worst forms of the latter, the symptoms are, from 
their earliest development, of a violent, if not of a malignant type. 
The pulse is, from the first, extremely rapid and thready, about 140 in 
the minute, and destitute of any force. Instead of there being con- 
stipation — which is the prevailing characteristic of simple peritonitis — 
diarrhoea sets in early, and the case, thus passing over, as it were, the 
initiatory stages of the disorder, plunges the patient at once into a state 
from which recovery may seem to be all but hopeless. The form is of 
a low type from the first, and the abdominal tumefaction commences at 
an earlier stage. It has also been remarked, that in this variety the 
pain begins in the region of the diaphragm, and radiates from that 
point, instead of from the pelvic region, over the whole peritoneal sur- 
face — and that with much greater rapidity than in the other form. It 
would appear, also, that in the more serious form, there is a remarkable 
difference in the exudative effects of the inflammatory action. In 
ordinary peritonitis, adhesive lymph is poured out, as an attempt at 
reparation on the part of nature, barring the further progress of the 
malady by gluing the parts together. But, in the more serious and 
fatal form, which has most likely its origin in contagion, the lymph is 
not adhesive, the inflammation is not circumscribed, and both Hulme 
and Leake found that, in these cases, the peritoneum is softened to 
such an extent that it actually seems gangrenous. 

False Peritonitis — Acute Tympanites. — We place these affections to- 
gether, not from any idea of their identity, but because they are con- 
ditions which may seriously embarrass the practitioner who may not be 
aware of the possibility of their occurrence, or, what is worse, may lead 
him, through a false diagnosis, to adopt methods of treatment which 
are the reverse of beneficial. The term, False Peritonitis, implies ab- 
dominal pain which is not inflammatory in its origin. It is, in all 
probability, due, either to intestinal irritation, or to some neuralgic 
affection of the abdominal walls in consequence of over-distension. 



XLIII.] METRITIS. 697 

The severity of the pain, the acceleration of the pulse, and the other 
constitutional symptoms to which it gives rise, may lead, very possibly, 
to a hasty conclusion that true peritonitis is the disease with which we 
have to deal. It would seem, however, from the description given by 
Dr. Fergusson of a malady which came constantly under his notice in 
the year 1827 and the early part of 1828, and to which he gave the same 
name, that this comparatively trivial affection may possess something 
of an epidemic character, although it may be relieved by the simplest 
remedies. The treatment which has been found most efficacious is the 
administration of a full opiate. 

The name, Acute Tympanites, was given by Dr. Ramsbotham to an 
affection which he himself had frequently observed, which he believed 
to be a variety of the intestinal irritation of Marshall Hall, and which 
is particularly interesting in this respect, that it very closely resembles 
ordinary puerperal peritonitis; so closely, indeed, that, to judge from 
the description given by Dr. Ramsbotham of the symptoms, it must 
be a matter of no small difficulty to distinguish the two affections. 
We are inclined to think, however, that he has given too much promi- 
nence to this affection as an independent puerperal disorder. 

Puerperal Metritis. — This is an affection which, uncomplicated, is of 
much less frequent occurrence than peritonitis. Hysteritis, or Metritis, 
under the ordinary childbed conditions, involves the idea of an acute 
inflammation, attacking tissues which are the seat of a very peculiar 
process of involution, a part of the physiological phenomena of gesta- 
tion. In a chronic form, it is by no means of unfrequent occurrence; 
but, under such circumstances, the result is not usually fatal. In the 
acute form, however, it has been observed to be very fatal, and to ter- 
minate, as in the case of peritonitis, with all the horrors, apparently, 
of puerperal fever. In the mode of access, it does not differ materially 
in its symptoms from peritonitis. The pain, however, is in this case 
referred more particularly to the hypogastric region, where the uterus 
may be distinguished of larger size, and sometimes harder, than is 
usual at the period. On a digital examination by the vagina, the na- 
ture of the cause is further revealed, by the heat and tenderness of the 
os uteri. This has been more frequently observed as a consequence of 
severe or protracted labor than the peritoneal variety ; and, in those 
cases in which a fatal result has ensued, extensive disorganization of 
the uterine tissues has been remarked. 

That an inflammatory affection, having its seat in the tissue proper 
of the uterus, may occur in childbed, we cannot dispute. But it may 
well be doubted whether many of the cases which have been referred 
to this category ought not rather to have been classed under a different 
head, — Uterine Phlebitis. To no one do we owe more, as regards the 
elucidation of this subject, and a painstaking investigation of the 
principal phenomena upon which it depends, than to Dr. Robert Lee. 
Opinions are, however, on this matter, far from harmonious. It is easy 
to conceive that, when the structure of the uterus is the seat of inflam- 
matory action, it can be no simple matter to determine, during life, 
what share the various tissues of the organ take in the morbid phenomena 
upon which the symptoms depend. If the evidence is not altogether 



698 PUERPERAL FEVER. [CHAP. 

clear, many facts combine to show that there are, in a considerable 
number of cases of puerperal fever, indications of great significance, 
which it is difficult to explain on any other hypothesis. The earlier 
symptoms may, indeed, admit of a different interpretation. At first 
there is more or less of rigor, followed by pyrexia, and accompanied 
with pain in the hypogastric region, generally referred more particu- 
larly to the iliac or ischiadic region of one side. The condition of the 
lochial and mammary secretions varies, although the general tendency 
is to the arrestment of both. These symptoms are usually developed 
within three or four days after delivery, and diarrhoea — and not, as in 
the case of peritonitis, constipation — is a prominent feature in the case. 
A tympanitic condition of the abdomen is almost uniformly observed, 
but the general tenderness, and other symptoms of peritonitis, are, for 
the most part, absent. The pulse is generally over 120, and sometimes 
reaches 150, and is soft and compressible from the first. Should reso- 
lution take place at this stage, it would, we believe, be impossible to 
say whether it has been a case of metritis, of phlebitis, of circumscribed 
peritonitis, or of any of these combined. 

If the case goes on, however, — and, sometimes in the worst form, 
very shortly after the seizure, — a new class of symptoms is developed, 
which alone can be held as pathognomonic of phlebitis, and of the 
blood poisoning, which has probably been the result of traumatic sep- 
ticaemia. The patient now complains of pain in various parts of the 
body, — most frequently in the neighborhood of the joints. In these 
situations, swellings and erysipelatous blushes appear, indicating the 
formation of secondary abscesses; or the abscesses may form internally 
either in the neighborhood of the uterus, or in distant organs, — such as 
the lungs, liver, or kidneys, — and occasionally they are imbedded 
deeply in the substance of the muscles. In some cases, the eye, and 
more commonly the left eye, has been the seat of violent destructive 
inflammation. Such formations of pus, if neither violent nor exten- 
sive, may, in some fortunate instances, be looked upon as critical, and 
in that sense favorable ; but, unfortunately, experience points to a con- 
trary result. In the worst cases, which have been observed in various 
epidemics, the tendency of the inflammatory process to attack the joints 
has been uniformly well marked, and the fearfully rapid nature of the 
action, the enormous quantity of pus which is formed, and the destruc- 
tion of the articular cartilages, have only too frequently been demon- 
strated in post-mortem examinations. 

Puerperal phlebitis may extend to the proper tissue of the uterus, 
and also to the peritoneum, — in which latter case the symptoms of 
peritoneal inflammation are superadded to those which more vaguelv 
indicate inflammation of the uterine veins. It would appear that, in a 
certain number of fatal cases, the action is confined to the uterus, — a 
result which may easily be explained by supposing that death had taken 
place before the toxaemia had time to produce its distal effects, in the 
production of abscess, etc. 

Vaginitis. — A protracted labor, in which the presenting part of the 
child has been allowed to remain too long in the same situation, may 
give rise, by pressure, to very severe inflammation, and even to slough- 



XLIII.] VAGINITIS. 699 

ing of the walls of the vagina. In so far as the latter form is concerned, 
its results have already been incidentally referred to, and consist mainly 
of vesico-vaginal fistula, and of contraction of the vagina, or the forma- 
tion of septa or bands, which ultimately constitute serious impediments 
to the progress of labor. There is, moreover, too much reason to be- 
lieve that the injudicious or unskilful use of instruments is a fruitful 
cause of this complication, and, indeed, rash operative procedure of any 
kind is not unlikely to produce it, by the actual mechanical violence 
which is thus inflicted. Inflammation of these tissues, however, even 
when it does not proceed to gangrene, may prove a very serious com- 
plication, and, by the constitutional irritation which it engenders, may 
give rise to serious apprehension. The risk, in such a case, is not only 
from the effects of local lesion, leading to septic action and puerperal 
fever, but from the danger which exists of the fire which is thus kindled 
spreading, and, by involving the uterus, the peritoneum, etc., giving 
rise to the panic of a general conflagration. It may, with reason, be 
objected, that an inflammatory affection of this kind should not be in- 
cluded under the generic designation of puerperal fever; but, while 
we admit the force of the observation, we recognize between it and the 
other inflammations, as between those and puerperal fever, such intimate 
pathological affinities, that we have no hesitation in placing them in 
juxtaposition. Inflammation of the vagina is accompanied with much 
swelling and tumefaction of the neighboring parts, and with an alter- 
ation in the nature of the discharge, which gives rise to more or less of 
foetor. The orifice of the urethra is involved, so that there is extreme 
difficulty or impossibility of micturition, and the condition of the vulva 
is such as to give rise to great annoyance, — these symptoms, taken 
together, affording a ready means of diagnosis. 

An affection, scarcely less important than this, although it has less 
direct connection with the subject of puerperal fever, is inflammation of 
the vagina, of an asthenic type, similar to what occasionally occurs in 
the course of typhus or other fevers. In this case, the whole vagina 
without any obvious local cause, is quickly involved in inflammation of 
the type alluded to, which defies all treatment, local or general, and 
rapidly passes into gangrene. The result of such violent and rapid 
action has been to involve the recto-vaginal septum in almost its whole 
extent, and to cause such a degree of vesico-vaginal intercommunica- 
tion as to defy even the improved remedial appliances of modern sur- 
gery. And, even when the destructive process has not involved those 
viscera, we have seen such implication of the perineal tissues, and con- 
sequent contraction, as to leave a bare exit for the menstrual flux. 

This is, of course, supposing that the patient survives. Unfortu- 
nately, however, when the inflammation assumes this type, recovery can 
scarcely be looked for, and the patient succumbs, either from the action 
of the morbid poison, from an extension inwards of the inflammation, 
or more frequently still, from these two causes combined. The ex- 
tremely rapid and feeble pulse, with cold extremities, and the offensive 
lochial discharge, indicate the type of the case; and soon the clammy 
surface, the anxious countenance, with hiccough, subsultus, and delirium, 
show only too clearly that the end is at hand. 



700 PUERPERAL FEVER. [CHAP. 

Another variety of puerperal inflammation is that form of the process, 
in which it has its seat in the Uterine Lymphatics. This was first 
described in France by M. Dance, and has since that time attracted the 
attention, both in this country and abroad, of most systematic writers. 
The presence of pus within the vessels of the lymphatic system has 
been repeatedly demonstrated; but, in so far as the symptoms are con- 
cerned, it would seem to be impossible to distinguish the affection from 
some others which have been described, and especially from uterine 
phlebitis. But, besides this, it is extremely improbable that, in the 
condition of the uterus at the puerperal period, angeioleucitis should be 
present without involving, more or less, the other tissues. And, perhaps, 
the converse may equally hold good, — that inflammation originating in 
other tissues may very readily pass to the lymphatic system. Although 
attempts have been made to show that the worst results of puerperal 
fever spring from inflammation of the lymphatics, Virchow has proved 
that lymphatic thrombosis is a favorable symptom in so far as it bars 
the transport of infected material. 

The various affections above detailed by no means embrace all the 
complications which may exist along with puerperal fever, whether in 
the relation to it of cause or of effect. And if we were to attempt an 
analysis of what may be called anomalous cases, we would but compli- 
cate still further a subject which we are specially anxious to put in as 
simple a light as possible. Some have placed phlegmasia dolens in 
this category, and in the cases in which that affection has been observed 
along with puerperal fever, it may well be supposed that both are the 
result of the same poison. It is quite obvious, however, that puerperal 
fever cannot be considered as a result of phlegmasia dolens ; otherwise, 
the latter affection would be looked upon with much apprehension, 
instead of involving, as it does, a favorable prognosis. The general 
state of the system in childbed, to which we have already so frequently 
referred, is singularly favorable to an extension of inflammatory action 
which has already been commenced. It need scarcely, therefore, cost 
us a moment of surprise, when we find the local inflammations of the 
puerperal state blazing out with a violence which defies extinction, and 
rapidly assuming the asthenic or adynamic features, which are held to 
be characteristic of the most fatal form of puerperal fever. 



XLIV.] CONTAGION. 701 



CHAPTER XLIV. 

PUERPERAL FEVER, ETC.— (Continued.) 

QUESTION OF CONTAGION — SEPTICEMIC INFECTION — OTHER SPECIFIC POISONS — ARE 
INFLAMMATORY CASES CONTAGIOUS? HISTORY OF EPIDEMICS — SYMPTOMS OF 
PUERPERAL FEVER — MORBID ANATOMY : MALIGNANT AND OTHER VARIETIES 
CONTRASTED : LESIONS OF OTHER ORGANS : PATHOLOGICAL APPEARANCES NO 
INDICATION OF THE VIRULENCE OF THE ATTACK — EVIDENCE OF A CHANGE OF 
TYPE IN PUERPERAL FEVERS — TREATMENT: ALL VARIETIES TO BE TREATED 
AS IF CONTAGIOUS: RECORDED RESULTS OF BLOODLETTING AND PURGING: 
GOOCH'S TREATMENT: CONNECTION OF METASTATIC INFLAMMATION WITH 
THROMBUS AND EMBOLISM: UTERINE PHLEBITIS: PURULENT FORMATIONS: 
EFFECT OF EMETICS : CALOMEL AND OPIUM ; TURPENTINE ; BLISTERS AND 
EXTERNAL APPLICATIONS; TONIC AND STIMULANT TREATMENT; TAPPING 
THE PERITONEUM : PROPHYLACTIC TREATMENT : CLEANLINESS : USE OF AN- 
TISEPTICS. 

Before going further in our attempt to describe the symptoms and 
treatment of the fevers of the puerperal state, it is proper that the sub- 
ject of contagion should receive that careful attention which its impor- 
tant practical bearing demands. For purposes of convenience, we may 
divide the question of contagion into two parts — 1st, Is puerperal fever 
contagious? — and, 2d, Are the "allied affections" contagious, and, if 
so, to what extent ? Some confusion may here arise as to the meaning 
of the word Contagion. " By a contagious disease," says Schroeder, 
" is meant one in which a specific poison is produced within a diseased 
organism, and which, transferred to other individuals, always produces 
the same specific disease, such as measles, scarlatina, small-pox, syphilis, 
etc." It will at once be noticed that if we concede that puerperal fever 
is not due to a specific poison, and at the same time admit the accuracy 
of Schroeder's definition of the word, we necessarily come to the con- 
clusion that puerperal fever is not a contagious disease. Such hair- 
splitting in regard to the meaning of words tends more frequently to 
confusion than to precision, and preferring, as we do, the word " con- 
tagious" to "communicable," we employ the former in its broader and 
more colloquial signification. 

In reply, then, to the first part of the question, we hesitate not for a 
moment to say that puerperal fever is contagious. According to Barker, 
there have been described, since 1740, upwards of two hundred epidemics 
of puerperal fever, and it would perhaps be sufficient, in most minds, 
to establish the truth of our proposition, carefully to peruse the details 
of one or two of these outbreaks, when the facts will be seen to be utterly 
irreconcilable with any other theory. Many observations, in themselves 
conclusive, are on record. " Two medical men," says Dr. Tyler Smith, 



702 PUERPERAL FEVER. [CHAP. 

" brothers and partners, attended, in the space of five months, twenty 
cases of midwifery. Of these fourteen were affected with puerperal 
fever — a fatal result ensuing in eight cases. The only other known 
death from puerperal fever, in the same town, within the period named, 
occurred in the case of a patient attended by a medical man who had 
assisted at the post-mortem of one of these puerperal patients. After 
this disastrous period, the two brothers relinquished all their midwifery 
engagements for one month, in which time five of their cases were 
attended by other practitioners, and no instance of fever occurred in 
the course of that month. They then returned, and several fatal cases 
again happened. . . . Dr. B-oberton, of Manchester, relates, per- 
haps, one of the most cogent instances of contagion and fatality on 
record. In the space of one calendar month, a certain midwife attended 
twenty cases belonging to a lying-in charity : of these, sixteen had puer- 
peral fever, and all died. The other midwives of the same charity, 
working in the same district, attended, in the same time, 380 cases, 
none of whom were affected with puerperal fever. In another large 
town, containing many thousands of inhabitants, and numerous medi- 
cal men, fifty-three cases of puerperal fever occurred. Of these, no 
less than forty happened in the practice of one medical man and his 
assistant." 

If these facts do not suffice to establish beyond all question the doc- 
trine of contagion, we would refer the reader to the works of Gooch, 
Routh, and Semelweiss, for evidence which appears to us to be un- 
answerable. Those who oppose the contagious view, attempt to account 
for such facts as have been quoted, by exaggerating the importance of 
epidemic influences. That epidemic and atmospheric influences bear 
upon the question we do not dispute, but that these will enable us to 
account for such cases as have been mentioned we cannot for a moment 
believe. The well-known occurrence of sporadic cases has also been 
urged against the doctrine of contagion. It is, however, so easy to 
account for such cases, by the septicemic theory, that we may pass this 
subject by without further comment. There are other influences which 
may well be assumed to have some share in the manifestation of the 
disease, such as the general health, temperament and constitutional 
vigor of the patient, and the circumstances under which she is confined. 
It has been repeatedly noticed that depressing mental emotions exercise 
a very marked effect, so that women who have been seduced are more 
prone to the disease than others. " Several of the worst cases I have 
seen," observes Dr. Churchill, "are mainly attributed to this cause." 

The doctrine of contagion is, in regard to septicemic puerperal fever, 
now all but universally received ; but in regard to the other varieties, 
and the allied inflammatory affections, the question presents itself for 
solution under conditions of greater difficulty. We have already ex- 
pressed our opinion that, although scarlatina may run its course in a 
woman who has been recently delivered, without the development of 
any marked symptoms beyond those of the specific fever, such cases 
very frequently pass into a condition which is identical with puerperal 
fever. But, beyond this, we are convinced that from the contagion 
thus developed, puerperal fever may be again and again reproduced ; 



XLIV.] CONTAGION. 703 

and, if we are right in this, the same remark will apply to the other 
specific fevers. 

One or two examples, illustrative of the manner in which a disease 
apparently identical with puerperal fever is generated by different 
poisons, may here be adduced. A patient was admitted by some over- 
sight, into the wards of the Dublin Lying-in Hospital, while laboring 
under typhus fever; but the error having been discovered, she was 
removed in a few hours. In the beds on the right hand and the left 
of this woman were two lying-in women ; both were attacked with 
puerperal fever, and both died. " In another case," says Dr. Tyler 
Smith, "a medical man was in constant attendance upon a patient 
suffering from gangrenous erysipelas, and, between the 8th of January 
and the 22d of March, attended the labors often women ; all had puer- 
peral fever, and eight of the patients died. This was in a town of 
moderate size, and no other patients in the place were known to have 
had puerperal fever. A remarkable instance, to the same effect, is 
related by Dr. Ingleby. Two practitioners attended a post-mortem 
where the patient died from this disease. The first was summoned, in 
one direction, to a midwifery patient, who w T as attacked with puerperal 
fever ; the other attended two cases in succession, both of whom w 7 ere 
seized with the same disease." The enormous mortality which at one 
time prevailed in the Lying-in Hospital of Vienna, gave rise to the 
belief that the disease was propagated by means of poison communicated 
by students who had recently been engaged in dissection, and the ob- 
servations of Dr. Semelweiss strongly corroborate the supposition. It 
seems to us, however, that this has been considerably exaggerated as a 
means of generation of the poison, as the evidence upon which the 
assumption rests is derived mainly, though not entirely, from lying-in 
hospitals. Medical students are proverbially careless in these matters, 
unless they are under strict supervision ; but it is somewhat strange 
that observation, extended over many years of the practice of a large 
lying-in charity, where the women are delivered by students and mid- 
wives exclusively at their own homes, has failed, in our own experi- 
ence, and in that of others, in recognizing any such marked septic 
influence as Semelweiss would have us anticipate. That the cadaveric 
poison has, undoubtedly, caused puerperal fever, is, however, quite 
enough to demand from every one the strictest precautions which can 
be devised, in order to avert so dreadful a calamity. 

In regard to the cases which may be supposed to be of inflammatory 
origin, the case is different. A simple inflammation is not communi- 
cable ; but when a case, at first simple, runs a rapid course, and ends 
fatally with the symptoms, let us suppose, of peritonitis and metritis 
combined, he would be a bold man who would venture to assert that 
there was no danger. We have never seen any reason to doubt that 
such a disease is communicable, and we have never been able to dis- 
cover any essential difference between it and the other varieties. We 
can scarcely imagine a more important practical point, than to be able 
to distinguish between what are, and what are not, communicable dis- 
eases of this class. But, unfortunately, practical points have rather 
been lost sight of in recent theoretical discussions, and for our part 



704 PUERPERAL FEVER. [CHAP. 

we would decline at present to give any opinion. For the practitioner 
the only safe rule is to look upon all such cases with suspicion, and to 
adopt the most stringent and careful precautions in every serious inflam- 
matory case, lest he should become the means of carrying death to his 
patients. 

Puerperal fevers have been met with under different forms, and as 
we might anticipate, the intensity or concentration of the poison is 
attended with a corresponding virulence in the symptoms. But, be- 
sides that, it would seem that in particular outbreaks of the disease, 
the cases resemble each other in manifesting certain complications, 
chiefly inflammatory. But instead of attempting to classify the differ- 
ent forms by talking of Malignant Fever, Hidrotid Fever, and the 
like, we prefer to make the attempt to treat the whole matter in a more 
comprehensive and simple manner. The older writers describe this 
affection as " childbed fever." The term " puerperal fever" dates from 
the beginning of last century. 

About 1746 a dreadful epidemic of puerperal fever appeared in Paris, 
a very accurate and full description of which was given by Malouin. 1 
The mortality was so frightful, that at the Hotel Dieu scarcely a single 
patient recovered. "The disease usually commenced with diarrhoea; 
the uterus became dry, hard, and painful : it was swollen, and the 
lochial discharge was irregular. The women then experienced pain in 
the bowels, particularly in the situation of the broad ligaments; the 
abdomen was tense; and to these symptoms was added headache, and 
sometimes cough. On the third or fourth day after delivery, the 
mammae became flaccid. On opening the bodies, curdled milk (sie) 
was found on the surface of the intestines, and a milky, serous fluid in 
the peritoneum. A similar fluid was found in the thorax of certain 
women ; and when the lungs were divided, they discharged a milky 
or putrid lymph." 

During the latter half of the eighteenth century, violent epidemics 
appear to have occurred in most of the principal towns of Europe, and 
of these the history and details have, in many instances, been preserved. 
The lying-in hospitals of Vienna, Paris, Lyons, and London, were all in 
turn attacked, with results, as regards maternal mortality, too dreadful 
to contemplate. In the great hospital at Vienna, for example, the death- 
rate has reached as high as one in six of all the women admitted. It 
would appear, further, that the disease, when once established in a 
locality, showed a tendency to return ; and, with regard to Paris, 
Tenon observes, that " it has come to prevail more and more, and to 
be, as it were, naturalized." We must not suppose, however, that the 
mortality from this cause was only observable in the statistics of lying- 
in hospitals, for the disease spread by contagion as well as by epidemic 
influences, through all classes of society ; and there can, we presume, 
be little doubt that the mortality was enormously increased by the ob- 
stinate incredulity of those who refused to admit that the disease was 
contagious. Still, it has always been upon lying-in hospitals that the 
great weight of mortality has fallen ; and, although improvements in 

1 Meraoires de l'Academie des Sciences. 1746. 



XLIV.] EPIDEMICS. 705 

construction, and the greater attention which is now paid to ventilation, 
cleanliness, and disinfection, have greatly reduced the hospital death- 
rate, there is no doubt that much yet requires to be accomplished before 
perfection is attained, or even approached. 

The statistics of the Loudon, Dublin, Edinburgh, and Aberdeen 
hospitals all show that, wherever observed, the disease was a very 
fatal one; but if we examine into the details given of previous epidem- 
ics, we cannot fail to be struck with the fact that there has been a great 
variety in their nature. When we find a history of an epidemic in 
which the mortality has been comparatively trifling, and bloodletting 
has obviously been attended with a beneficial result, we may well doubt 
whether this should be called puerperal fever. But, putting aside for 
the moment such doubtful epidemics, we find that when the asthenic 
type of the disease is perfectly marked from the outset, the local lesions 
vary at different times; and we thus observe that in some epidemics 
the peritoneum is chiefly involved, while in others the affection of the 
joints, and other distant parts, may be held to indicate the presence of 
uterine phlebitis as the special characteristic of the prevailing epidemic. 
Another fact which stands out very prominently in the history of epi- 
demics, is the marked variation in the intensity of the disease, or the 
virulence of the poison, so that in one case we have a low percentage of 
deaths, while in another the patients are, as it were, struck dead by a 
fever which runs its course in a few hours. 

It is a fact, beyond all question, that the disease we are now consid- 
ering attains its maximum of intensity in hospital epidemics. It 
usually originates in the course of the second, third, or fourth day, 
although sometimes later, and cases have been recorded in which it has 
come on before delivery. It is sometimes ushered in by a rigor, but 
this is far from being invariable; and, indeed, it may be remarked that 
the violence of the rigor is in this case much less marked than, in some 
instances, where the impending disorder is comparatively trivial. The 
patient is conscious, from the first, of a feeling of great depression, 
which is often accompanied with headache and uneasiness at the pre- 
cordial region. There has often been observed, even thus early, a 
haggard, anxious expression of countenance, as if she were in dread of 
an impending calamity. The pulse is feeble, or at least compressible, 
and is seldom less than 130, rising in many cases to 150 and upwards. 
Extreme rapidity is a very bad sign, especially if associated with a 
high temperature. There may sometimes be a rigor and a hot stage, 
quickly followed by free perspiration, which, supposing it to be criti- 
cal, we may look upon as a favorable augury ; but, as the case goes on, 
we soon observe that the discharge from the skin brings no relief to the 
symptoms : it continues profuse to the end, and a peculiar odor has 
sometimes been observed. Those instances in which the perspiration 
constitutes a peculiar feature of the case are not common, but were con- 
sidered of sufficient importance by Blundell to warrant him in describ- 
ing a distinct variety of puerperal fever, which he, from the leading 
symptom, called "Hidrosis," or " Hidrotid Fever." 

Generally speaking, however, the skin is hot and dry, although to- 
wards the termination of a fatal case it becomes cold, damp, and 

45 



706 PUERPERAL FEVER. [CHAP. 

clammy. The effect produced on the milk and lochia is variable ; and 
there are even cases in which these discharges are more than usually 
abundant. Vomiting is by no means an uncommon symptom ; but it 
does not generally come on very early, and the matter ejected is some- 
times dark in color, like coffee-grounds, and occasionally very offen- 
sive. Diarrhoea is, as we have already seen, an almost invariable 
symptom in the later stages of those inflammatory affections which pass 
into puerperal fever; but, in cases of the ordinary type, diarrhoea often 
comes on at a much earlier stage, when the offensive nature of the 
evacuations often indicates still further the extent to which the digest- 
ive functions ato involved. The tongue presents at first no distinctive 
character, but, as the case rapidly advances, the deep fur — white or 
brownish, moist or dry — is a further index of the extent to which the 
normal functions are disturbed. Marked delirium is not usual, but 
there is often observed an excited condition in which the patient ex- 
hibits a peculiar tendency to loquacity, amounting, it may be, to slight 
delirium in awakening from sleep. 

In a very large proportion of cases, the peritoneum or uterus, or 
both, are involved. Thus, one of the earliest symptoms, after the dis- 
ease has been thoroughly established, is abdominal pain, which either 
originates in the hypogastric region, or, more exceptionally, in the 
epigastrium. The pain is excessively acute, so that the patient will 
frequently complain of the weight of the bed-clothes; and it is soon 
accompanied with more or less swelling, or tumefaction, — the enlarge- 
ment being due, in the first instance, to flatulent distension, and, sub- 
sequently, to fluid effusion, which is poured into the cavity of the ab- 
domen. In some cases, the pain is associated with enlargement of the 
uterus, which may be recognized through the abdominal walls. This 
has sometimes given rise to the idea, when the general symptoms were 
not carefully observed, that the pain was due to those irregular con- 
tractions of the organ which are commonly known as after-pains, and, 
under this impression, valuable time has been lost. 

As the abdominal distension increases, which often happens 'with 
extreme rapidity, the sufferings of the patient are proportionally aug- 
mented. She now lies on her back, breathing rapidly, sometimes with 
her knees drawn np, and exhibiting on her countenance that appear- 
ance of ghastly distress which is so painful to witness. The surface 
and extremities become cold ; the mechanical impediments to perfect 
respiration give something of lividity to the countenance; and the 
symptoms, becoming otherwise more grave, indicate that the period 
has been reached when hope may be well-nigh abandoned. At this 
period, the abdominal pain, tenderness, and tension often diminish ; 
and, but for the ominous pulse and countenance, we might fancy that 
the patient was better. The diarrhoea continues, the stools being 
passed in bed ; vomiting occurs, without any retching, of a dark or 
greenish matter; and the patient may now breathe with greater ease. 
The pulse is undiminished in frequency, but it is otherwise changed 
for the worse, as is indicated by its thready or imperceptible character. 
The intellect generally remains clear to the end ; but in some cases low 



XLIV.] MORBID ANATOMY. 707 

muttering delirium, subsultus tendinum, and other similar symptoms, 
come on before death ensues. 

Such symptoms are, as will be observed, almost identical with those 
which have been described as characteristic of the fatal inflammatory 
affections previously mentioned. If we attempt to follow the descrip- 
tion and classification of various authors, we find that the varieties and 
divisions of puerperal fever are infinite, and are, were we disposed still 
further to classify, susceptible of more elaborate subdivisions still. For 
our present purpose, however, it may suffice to observe, that although 
we believe the symptoms above detailed to be among the more impor- 
tant of those which arise in the course of an ordinary septicemic case, 
other varieties may exhibit themselves, in the experience of any man, 
which may differ in important particulars. But we recognize in this 
admission no reason for more elaborate classification of a subject which 
has already been classified out of all shape, and which, plastic as it is, 
it is difficult to mould into a simple, comprehensive, and comprehen- 
sible form. 

Morbid Anatomy. — The various forms under which puerperal fever 
may manifest itself involves, almost necessarily, a corresponding variety 
in the appearances produced in the different tissues which may be im- 
plicated. In the case of the post-partum inflammatory affections which, 
after a somewhat longer course, apparently pass into puerperal fever, 
and thence to a fatal result, the appearances of an ordinary local inflam- 
mation are, as we might confidently anticipate, more distinctly revealed. 
In peritonitis, for example, the more closely the case resembles, in its 
symptoms and progress, the purely local disease, the more closely do 
the morbid appearances correspond. When the septic infection is con- 
centrated or malignant, as in hospital epidemics, the fatal result ensues 
with such rapidity that there are really no marked post-mortem appear- 
ances. In ordinary cases, however, the lesions are conspicuous. In 
many cases there may be observed in the vulva, vagina, or cervix, or 
at the site of the placenta, an ulcerative action at the margin of the 
existing wound. This is called the " puerperal ulcer," and the neigh- 
boring parts will be found to have participated more or less in the 
unhealthy action. Inflammation, softening, and even sloughing or 
gangrene of the mucous membrane of the womb, is often noted, the 
extent of the changes corresponding in some degree to the virulence of 
the morbid action. The pelvic connective tissue is very generally the 
seat of a diffuse inflammatory oedema, to the development of which the 
relaxed condition of the parts gives mechanical encouragement. The 
inflammatory process has also been traced to the lymphatics, the veins, 
and the parenchyma of the uterus, and in a large proportion of the 
fatal cases the inflammation will be found to have spread to the peri- 
toneum and from that again by mere continuity of tissue to structures 
more remote. 

In some cases there is found clear pathological evidence of inflam- 
matory action in distant organs which cannot have been transmitted 
thither by continuity. These appearances will generally be found to 
have reference to symptoms manifested during life, and constitute what 
is usually called metastasis. A new interest has been given to this 



708 PUERPERAL FEVER. [CHAP. 

subject by the discoveries of Virchow and his followers in regard to 
thrombus and embolism, and we can have little hesitation in admitting 
the possibility of a fragment of an infected and disintegrated thrombus 
being conveyed by the circulation to a point in the arterial system, 
where, being arrested, it becomes a fresh centre for violent inflamma- 
tion. Billroth and Waldeyer refer all circumscribed metastatic inflam- 
mation to embolism, but in the present state of our knowledge this is 
certainly going too far, although we may admit that this theory gives 
us by far the most satisfactory explanation of the phenomena of metas- 
tatic inflammation in these cases, and more particularly of the formation 
of purulent deposits in distant organs. 

In regard to these distant abscesses, it may here be remarked that 
they have most frequently been found associated with the malignant 
or epidemic variety of the disease, of which we have many descriptions, 
chiefly from hospital experience. On this point, Boivin and Duges 
observe that "pus is sometimes found even in the substance of the 
womb, and generally nearer to its exterior than its interior surface. 
Thus, pus collects into distinct abscesses, from one to five inches in 
diameter, — sometimes into a simple or multilocular deposit, with a 
greenish or viscous appearance ; at other times it is infiltrated into the 
fleshy fibres, imparting to them a reddish-yellow color, perceptible 
through the peritoneum. In this latter case, tumors form — which are 
sometimes hard and projecting — upon the fundus uteri; at other times, 
they are flattened, soft, and broad. These latter come further down 
towards the lateral regions, and often form a continuation, together 
with purulent infiltration between the laminae of the broad ligaments, 
with the cellular tissue of the pelvis and the substance of the ovarian 
ligaments." This has reference to certain secondary purulent forma- 
tions which we shall have occasion to notice in our next chapter. There 
is here also, as in the peritoneal form when rapidly fatal, a tendency to 
turbid effusion into the serous cavities. 

The most interesting, however, of all the points upon which patho- 
logical anatomy may be expected to throw light, are those which are con- 
nected with uterine phlebitis, an affection which has, as we have seen, 
been supposed by eminent modern writers on the subject to bear the 
most intimate relation to true puerperal fever. The primary and es- 
sential morbid change in this variety is inferred from the condition 
in which the ovarian and uterine veins and their branches within the 
uterus have been found. We do not doubt that here, as in phlegmasia 
dolens, erroneous inferences have been drawn from a mere discoloration 
of the lining membrane of the vein, associated with the presence of a 
clot; but many of the appearances which have frequently been observed 
and described, are so unequivocal, that the existence of true phlebitis 
must be conceded. Of this nature are thickening, contraction, and ab- 
sorption of the tissues of the vein, and the presence of lymph and pus 
as obvious products of local inflammatory action. Certainly in some 
cases, and probably in many, this inflammation of the veins is asso- 
ciated with softening of the muscular tissue, or some other sign equally 
significant of metritis. 

In the less severe cases, it will probably be found that the inflam- 



XLIV.] MORBID ANATOMY. 709 

matory process has not extended further than the veins of the uterus 
itself, or the veins which directly communicate with it; but, in some 
instances, evidence of inflammation is said to have been traced as high 
as the renal veins, or even the vena cava itself, although there is reason 
to believe that, in these latter examples, the mere presence of pus in the 
vein has sometimes been admitted as evidence of inflammation of its 
structure. 

The presence of pus within the veins, in the region of the uterus, is 
to be accounted for chiefly by the changes which take place in the blood- 
clot, which is the more immediate result of phlebitis. Coagulation is, 
as we have seen, equally the result of pysemic action ; but we are here 
considering it as the effect of, or, at all events, as associated with, true 
inflammation of the veins. From the disintegration and decomposition 
of the blood-clot, pus is evolved, and becomes the cause of some of the 
more characteristic of the morbid appearances of uterine phlebitis. 
The circulating medium is poisoned with pus, the result of which may 
be immediate septic coagulation ; or, the poison being carried, by de- 
tached portions of the thrombus or otherwise, to distant localities, it 
there produces the secondary phenomena which are disclosed after death. 
In a large proportion of these cases, swellings are observed in the neigh- 
borhood of the joints, which, on being freely incised, give exit to pus. 
In the worst cases, pus is found within the joint itself, and the liga- 
ments and cartilaginous surfaces afford proof of a rapidly destructive 
inflammation. If the eye has been affected, evidence will there be found 
of inflammation, of equal violence, although limited in extent. Abscess 
may also be found in the muscles or cellular tissue of the limbs; and, 
in other cases, what has been supposed to be an abscess, has turned out 
on examination, to be an effusion of sero-sanguineous fluid. The brain 
is rarely affected; but, within the cavity of the chest, clear evidence 
has often been observed of that metastasis of inflammation, to which 
allusion has already been made, sometimes within the lungs, — which 
have been found condensed, of a dull-red color, and infiltrated with 
purulent matter, — while, at other times, the violence of the disease 
seems to have expended itself mainly on the pleura. The heart is often 
enlarged and softened; and, within the pericardium, lymph and serum 
may, with the usual alterations in the membrane itself, afford conclu- 
sive proof that inflammation has been present here also. The various 
portions of the intestinal canal, from the stomach to the rectum, have, 
in exceptional instances, been found to have been severely affected, 
usually by a simple extension of the inflammatory process from the 
contiguous position of the peritoneum. Ulceration and perforation of 
the stomach have been noted in some of those cases. The spleen and 
liver have also been found to be extensively disorganized, and their 
tissues the seat of single or multiple abscesses. In the greater number 
of the cases which were examined by Dr. Hulrne, he found the omentum 
inflamed, and frequently black and gangrenous. In no small propor- 
tion of fatal cases, the kidneys have been found to present evidence of 
similar disorganization, obviously the result of violent inflammation : 
generally speaking, one kidney only is affected. 

In the malignant variety of the fever, the following indications in 



710 PUERPERAL FEVER. [CHAP. 

addition to those which have been already detailed, are mentioned by 
Dr. Copeland, in his Dictionary of Practical Medicine. In several 
cases, in which bloodletting had been practiced, he observed, that "on 
every occasion I was struck by the peculiar faint odor, and very dark 
hue of the blood; by the very soft state of the clot when the blood did 
separate into crassamentum and serum; by the appearance which occa- 
sionally presented itself, of a mass exactly resembling, in color and 
consistence, a common jelly, the coloring matter covering the bottom of 
the vessel in the form of a precipitate ; and by, in some instances, a 
separation only of serum, the large, loose, gelatinous crassamentum con- 
sisting chiefly of this jelly-like matter, the lowest stratum of which con- 
tained the black or dark-brown precipitate of coloring matter. These 
appearances of the blood were presented in several cases in the hospital, 
in 1823 and three or four subsequent years, in which cases blood had 
been taken before I saw the patients. It may here be remarked, that 
I have seen many cases of this form of the disease, in which leeches 
had been applied to the abdomen ; but in nearly all, and especially in 
those which occurred in the hospital, the blood which flowed from the 
bites did not coagulate; and great difficulty, almost amounting to an 
impossibility, of arresting the bleeding from them was generally ob- 
served, owing both to the state of this fluid, and to the impaired vital 
cohesion of the tissues, characterizing the advanced stage of the malig- 
nant form of this domestic pestilence." This condition of the blood, 
which has frequently been remarked, points very significantly to the 
operation of some powerful morbid poison. In the cases which prove 
most rapidly fatal, nothing may, indeed, be revealed on examination, 
beyond this peculiar condition of the blood, and, it may be, a little 
turbid serum in the peritoneum and the other serous cavities. 

The pathological appearances, then, are no reliable indication of the 
virulence of the attack, as has also been frequently observed in the case 
of other febrile diseases which prove rapidly fatal. Generally speaking, 
however, in very severe cases, the extent of the local lesions is commen- 
surate with the severity of the attack ; and, although we may meet 
with cases ultimately fatal, in which the metro-peritoneal symptoms 
are moderate in degree, a careful examination will usually disclose irre- 
fragable evidence of violent local inflammation. While, therefore, the 
appearances are often such as to indicate a degree of malignancy and 
rapid action, which can only be explained on the hypothesis of puer- 
peral fever, we are aware of no mode of disclosure by which morbid 
anatomy can reveal to us, with even an approach to certainty, how we 
may distinguish between the various types of the disease. The post- 
mortem appearances in the sporadic variety are certainly much less for- 
midable than in the epidemic form ; and, indeed, it is evident that the 
description both of symptoms and of morbid appearances, which we 
read in many admirable works, is founded almost entirely upon an 
experience of hospital epidemics ; whereas it should be clearly under- 
stood that the disease in sporadic cases, or even when communicated 
by contagion in private practice, is, as a rule, much less disastrous in 
its results than the once dreadful, and still formidable scourge of lying- 
in hospitals. 



XLIV.] TREATMENT. 711 

Another point which we have already alluded to, in reference to the 
symptoms, is also borne out by a careful analysis of recorded morbid 
phenomena. This is the tendency in the disease to change its type or 
form, as evidenced by the tissues which, in successive epidemics, or 
even at short intervals during the same epidemic visitation, are mainly 
affected. It were easy to multiply illustrations of this, but we shall, 
in the meantime, content ourselves with the following example from the 
experience of M. Tonnelle, whose name has already been mentioned in 
connection with the subject. "Softening of the uterus," he states, 
" after showing itself frequently in the first half of the year 1822, and 
particularly about January, disappeared entirely in the months of July 
and August, which were characterized, in a remarkable manner, by the 
frequency of inflammation of the veins. Afterwards, it began to rage 
anew with great violence in September and October, and again disap- 
peared in the last two months, during which term the mortality was 
inconsiderable." 

Treatment. — The treatment of puerperal fever varies according to the 
class to which each case belongs. If, however, we take what is at once 
the most simple and comprehensive view of this part of our subject, we 
shall find that the symptoms and morbid appearances seem to reveal the 
fact that we have a single disease to treat, — whatever we may choose to 
call it, — and that our treatment will only be modified by the stage of 
the disease, the nature of the symptoms, and the character of the com- 
plications which may arise. Nothing can well be imagined more ab- 
surd, and nothing, in fact, has been more disastrous in its results, than 
to manage all cases of puerperal fever upon one and the same principle. 
One feature, indeed, is common to all cases, and consists in the conta- 
gious nature of the disease. This is the leading idea, which, more than 
anything else, we would again impress upon the student with all the 
emphasis at our command. Whether the case be one of peritonitis, 
metritis, or malignant puerperal fever, the risk of contagion must 
always be borne in mind ; and although we must admit that the danger 
is much less in, for example, simple peritonitis, we can never be sure 
that it is absent, and therefore we should treat every case, without ex- 
ception, as if its contagious nature were already demonstrated. 

A further reference to the history of various epidemics shows, with 
remarkable clearness, that methods of treatment which have been found 
useful at one time have proved the reverse of beneficial at another. 
Dr. Gordon, who, in 1789, when the disease appeared in Aberdeen, 
saw a large number of cases, wrote, several years afterwards, a most 
excellent treatise on the subject, in which he drew attention, with much 
force of argument and illustration, to a new and successful method of 
practice, by means of the bold and early use of the lancet, — taking 
twenty or twenty-four ounces at once, and, if necessary, ten more soon 
afterwards. "When I took away," he says, "only ten or twelve 
ounces of blood from my patient, she always died; but when I had the 
courage to take away twenty or twenty-four ounces at one bleeding, in 
the beginning of the disease (i. e., within six or eight hours after the 
attack) the patient never failed to recover. After the bleeding, it was my 
practice to bring on a diarrhoea, which, when excited, I found necessary 



712 PUERPERAL FEVER. [CHAP. 

to continue through the whole course of the disease, till it was entirely 
conquered." Nothing, we would say, were we reading of a new and 
unknown disease, can be more simple than this ; nothing more clear 
than the indications of practice. In an epidemic which occurred in 
Leeds early in the present century, the treatment of Dr. Gordon was 
energetically adopted by Mr. Hey ; and although, prior to this, every 
case that had come within his knowledge died, no sooner did he purge 
his patients and bleed them early, to the extent of thirty, forty, and 
even fifty ounces, than they recovered, in the proportion of thirty cases 
out of thirty-three. Such facts, which were further corroborated by 
Armstrong, Mackintosh, and others, were held to be so significant, that 
for many years the treatment of epidemic and contagious puerperal 
diseases was, simply, heroic bloodletting. 

About 1829, a remarkable essay was published by Gooch on what 
he terms " The Peritoneal Fevers of Lying-in Women," which effectu- 
ally staggered the belief of those who had clung most persistently to 
the bold measure of Gordon. It would seem that, before this, doubt, 
founded upon unsuccessful results in treatment, had sprung up in the 
minds of many ; but, till Gooch wrote, no one had had the courage to 
controvert ideas so generally entertained. One of the first points to 
which he calls his readers' attention, and which he states with great 
force is the marked distinction which subsists between various epidemics, 
and the result of their treatment at the hands of different observers, 
who imagined that they were all treating the same disease. He makes 
it quite obvious that the disease of which William Hunter says, " of 
those attacked by this disease, treat them in what manner you will, at 
least three out of four will die," cannot be, in all respects, the same as 
Dr. Butter treated in Derbyshire, "with ten grains of rhubarb and ten 
grains of cordial confection every day," without a single fatal result. 
Nor can it be possible that the fatal scourge of the London and Paris 
hospitals can be the same as that observed by Richter of Gottingen, of 
which he observes, " I have often seen the childbed fever, and always 
treated it successfully." Gooch began his practice with a decided 
prejudice in favor of bloodletting, and his results seem to have been 
so far satisfactory, when he saw the patients early ; but when several 
days had been allowed to elapse, the issue was almost uniformly fatal. 
As his experience increased, he fully recognized the fact, that a blind 
and slavish adherence to the lancet sometimes inflicted irreparable injury 
upon the patient. 

In 1823, Dr. Copeland was appointed consulting physician to Queen 
Charlotte's Hospital, and the result of his experience is given by Dr. 
Fergusson. " The disease was malignant, and often ran its fatal course 
in twenty-four hours from the first appearance of the symptoms. . . . 
The treatment ultimately adopted by Dr. Copeland for this malady was 
boldly stimulant. Immediately upon the appearance of the symptoms, 
a bolus containing from eight to sixteen grains of camphor, from ten to 
twenty grains of calomel, and from one to three of opium was given, 
and repeated in four, five, or six hours. The dose of camphor was 
very rarely less, and but seldom above that named, and the interval 
between the two doses sometimes only three hours, but never longer 



XLIV.] TREATMENT. 713 

than six hours. The dose of opium in the second and subsequent 
boluses was regulated according to the effect of the first. Soon after 
the second bolus was administered, about half an ounce of spirits of 
turpentine and an equal quantity of castor oil was given, on the surface 
of some aromatic water; and if these did not operate fully on the bowels 
within three hours, the same medicines in double and treble quantity 
were administered in enemata. The bolus just mentioned was still 
continued at the same intervals, or after five or six hours from the 
exhibition of the second or preceding one. Very soon afterwards, and 
generally subsequent to the administration of the turpentine draught 
and enema, a large piece of flannel folded several times, and sufficient 
thus to cover the whole abdomen, was directed to be wrung as dry as 
possible out of very hot water, to be instantly freely sprinkled with 
spirits of turpentine, and applied over the abdomen, to be closely 
covered by wash leather or a dry cloth, and to be kept thus applied for 
some time, or renewed until erubescence of the surface of the abdomen 
was produced. The success of the above treatment in the malignant 
form I found to be almost complete, for scarcely a case terminated fatally 
in which it was early resorted to." 

It is quite clear that the stimulating treatment detailed in the above 
extract, and which was attended with results so satisfactory, must have 
been directed against a fever of a different type from that which was 
encountered by Gordon and Hey. The more, indeed, do we study the 
history of puerperal fever, the more prominently does the fact stand 
out that the type of the disease has varied much during the last hundred 
years; and that while, in one epidemic, the sthenic or inflammatory 
nature of the symptoms has been such as to warrant the boldest anti- 
phlogistic treatment, in another, the asthenic type has prevailed from 
the first, when stimulant treatment has alone been attended with suc- 
cess. We shall not here enter upon the question, whether or not there 
has been, as some have alleged, a. general change in the type of all 
diseases from the sthenic to the asthenic form ; but, admitting the force 
of many facts which have been advanced in support of this assertion, 
we confess to having entertained all along a strong impression that the 
idea has led to an all but invariable discontinuance of general blood- 
letting as a feature of modern practice, which is an exaggeration, and, 
as such, to some extent, an error. It is quite clear, however, that 
during the last forty years the type of puerperal fever has been usually, 
although not invariably, asthenic or adynamic. 

All this leads directly to the practical conclusion that, although the 
nature of the treatment to be adopted should depend upon the type 
under which the disorder presents itself, and also upon the stage at 
which the case is brought under the notice of the physician, that type 
is, in the experience of all modern practitioners, mainly asthenic. There 
is no single plan of treatment applicable alike to all cases. Indiscrim- 
inate bloodletting is sure to lead to disaster, and invariable stimulation 
is not free from risk. It is the first duty, therefore, of the judicious 
practitioner to determine the nature of the individual case, and the 
special treatment proper to it. The cases to which bloodletting is most 
applicable are undoubtedly those in which the earliest symptoms indi- 



714: PUERPERAL FEVER. [CHAP. 

cate acute inflammation of the peritoneum, of the uterus, or, more 
probably still, of both. When a patient, therefore, of robust constitu- 
tion, complains, after a rigor, of acute hypogastric pain, which is ac- 
companied by a rapid, incompressible pulse, throbbing temples, and 
suffused countenance, we should not hesitate to apply from ten to twenty 
leeches over the surface of the abdomen. Few persons nowadays 
would be bold enongh to bleed from the arm, but it by no means fol- 
lows that there are no cases in which this would not be the more judi- 
cious treatment. If the thing is to be done at all, it must be done 
boldly; and, above all, it must be done early, for, if the patient has 
passed the acute stage, to bleed her is probably to hasten her doom. It 
is to be remembered, however, that cases do occur in which the symp- 
toms are such as to baffle even the most experienced observer ; and in 
such instances it has been suggested that the bleeding should be more 
tentative in its nature, the effect of the flow being carefully noted, and 
only continued if the pulse and other indications show that it is being 
well borne. 

It does not, in the least, matter what names we give to those acute 
affections upon which bloodletting has been found to produce so de- 
cidedly beneficial an effect. For all practical purposes, it is sufficient 
carefully to distinguish between them and the purely septic cases, in 
which bloodletting is inadvisable, unless inflammation should arise as 
a complication, and at an early stage. A rapid compressible pulse, 
distended abdomen, diarrhoea, and the characteristic appearance in the 
countenance of ghastly distress, are among the more important of the 
signs which indicate that depletion must not be ventured upon. 

The same simple rule must be our guide as to the administration of 
purgatives. Free purgation is generally proper, in the cases to which 
venesection is applicable; and it is well known that, in peritonitis, 
constipation is an almost invariable symptom. Our object is to elimi- 
nate the septic material through the channel of the alimentary canal. 
The extent to which purgation is to be be carried, and the class of med- 
icine to be selected, must be determined, in each case, according to the 
judgment of the medical attendant; but it may be well for him to re- 
member that, in some fatal cases, the morbid appearances have been 
such as to suggest the probability of an irritant action from violent 
drastics having had some share in the result. It is better, therefore, 
when the bowels do not respond to a sufficient dose, rather to supple- 
ment that by an enema, than to run the risk of further irritation. In 
the later stages of the ordinary disease or in the malignant variety, 
strong purgatives are contraindicated, not only because diarrhoea is a 
common symptom towards the end, but because there is no hope of a 
beneficial derivative action from the bowels. To such a case, the milder- 
laxatives, or enemata containing turpentine, are appropriate. 

[The disease to which the author evidently alludes, in speaking of 
bloodletting, is peritonitis, to which the term puerperal may be appro- 
priately prefixed. We have seen a number of cases of this affection, and 
have resorted to bloodletting occasionally for its relief. We know of no 
remedy the use of which is followed by more brilliant results, but to be 
of any service it must be employed at the outset of the disease, certainly 



XLIV.] TREATMENT. 715 

within the first twenty-four hours after its commencement. The patient 
should be bled when sitting up in bed, and the flow should not be 
checked till syncope is about to occur. To be useful, venesection must 
be employed boldly. We have seen it terminate the disease at once. 

There are few American practitioners, however, who follow either 
general or local depletion by the use of purgatives. These are very 
universally condemned in this country as dangerous remedies in this 
disease. They excite peristaltic action of the bowels, and increase 
rather than relieve the irritation and inflammation. 

The depletion should be followed by the use of veratrum viride and 
opium. Of the former enough should be given to keep the pulse 
thoroughly under control. It should be kept at 75 or 80 per minute. 
Opium relieves pain, quiets emotional disturbance, allays nervous irri- 
tability, and arrests the peristaltic movements of the bowels. It has 
to be given boldly and in large quantities, because in this disease there 
is a remarkable tolerance of its effects. Professor Alonzo Clark, with 
whom this plan of treatment originated, says that a woman " who was 
unaccustomed to the use of opium in health, and who was not intem- 
perate, took the first twenty -six hours, of opium and sulphate of mor- 
phia, a quantity equivalent to 106 grains of opium ; in the second 
twenty-four hours she took 472 grains ; on the third day, 236 grains ; on 
the fourth day, 120 grains; on the fifth day, 54 grains; on the sixth 
day, 22 grains ; and on the seventh, 8 grains/' It is therefore apparent 
that we are to be guided by the effect produced rather than by the 
quantity of medicine administered. My own rule is to give enough 
of some fluid preparation of opium to bring the respirations down to 
12 per minute. The probabilities are that they will fall to 10 or even 
to 8, which need occasion no alarm if the medicine has been carefully 
given. To produce this impression it is safe to commence with doses 
of one-third or one-half of a grain of morphia in solution, given every 
hour, and continued umtil the desired effect is produced. If it fails in 
this, the dose must be increased until the woman is semi-narcotized. 
The effect must be produced, no matter what quantity of opium is 
needed to do it. If vomiting interferes with the administration of the 
remedy by the stomach, it may be given by hypodermic injection. 

The opiate often has to be continued for many days. The tolerance 
of the patient is the best guide to follow in deciding when to diminish 
the quantity or to stop its use. As the disease improves, the tolerance 
diminishes. Patients are often injured by stopping the opium too soon. 
This fact cannot be too strongly impressed upon the mind of the young 
practitioner. 

The local treatment of peritonitis is important. Turpentine stupes 
applied to the abdomen, and kept on as long as the patient will bear 
them, are useful as counterirritants, while, as Prof. Barker says, 
enough of the remedy is probably absorbed to produce some constitu- 
tional effect. This is shown in the restoration of the suspended lochial 
discharge, the diminution of the tympany, and the stimulation of the 
patient. When the turpentine is removed, the abdomen should be 
covered with soft cloths, wet with warm water, to which laudanum may 
or may not be added, according to circumstances. The whole should be 



716 PUERPERAL FEVER. [CHAP. 

surrounded with oiled silk. We have seen blisters applied in the early 
stage of the disease, but at this time they are not only useless, but are 
actually injurious. During the second stage, after the acute symptoms 
have disappeared, a blister is useful in the treatment of the inflammatory 
indurations which result from the disease. Under these circumstances 
it not only subdues the remaining inflammation, but it materially as- 
sists in effecting the resolution and absorption of the inflammatory 
formations in the peritoneal cavity. 

If the symptoms of purulent infection should supervene, in conse- 
quence of an attack of general peritonitis, the patient must be treated 
as in other cases of pyaemia. — P.] 

In the worst forms of the disease, and especially in hospital epi- 
demics, the power of medicine and the skill of the practitioner are 
alike set at defiance ; but, however desperate the symptoms, and ap- 
parently hopeless the prognosis, we must persevere so long as life lasts. 
Between simple puerperal peritonitis and the malignant fever — which 
is as deadly as the plague — infinite varieties may be observed ; but 
the management of all will be more successful if we proceed upon gen- 
eral principles, rather than minute and special distinctions. We shall, 
therefore, content ourselves by mentioning, in addition to the means 
already detailed, the various remedies which have been found useful by 
the most experienced and able of those who have written on the subject. 

M. Doulcet, in the course of a severe epidemic at the Hotel Dieu, 
thought of using emetics at an early stage of the disease, and the 
results, as detailed by him, were eminently satisfactory. Subsequent 
expe3*ience, however, has not realized, in the hands of others, the hopes 
which M. Doulcet's statements seemed to encourage. The emetic em- 
ployed was ipecacuanha, and it was repeated daily until the symptoms 
were subdued — a potion being administered in the interval, composed 
of oil of almonds, syrup of marshmallow, and Kermes' mineral. At 
one time, calomel was given very freely in those cases, and, on the 
whole, as it would appear, with benefit. On this point Gooch observes, 
"I have never given it systematically in a number of cases, but what 
experience I have is in its favor. In the Westminster Lying-in Hos- 
pital, where ten or twenty grains of calomel used to be given every 
day, with purgatives, the gums sometimes were affected, and these 
patients invariably recovered." The fact of all those recovering where 
the gums were affected may, however, be otherwise explained, on the 
supposition that if they live long enough for mercury to produce its 
constitutional effect, the urgent danger of the case has necessarily, in 
some measure, passed. It will generally be found advantageous to 
combine opium with the mercury, but, in this respect, much will depend 
upon the stage which the disease has reached. Spirits of turpentine 
has been very highly recommended in the treatment of puerperal 
fever, but the effects produced by its internal administration seem to 
have been somewhat exaggerated. Flatulent distension of the bowels 
is, however, so frequent a complication, that we would naturally antici- 
pate some benefit from this drug, although, perhaps, it would be more 
correctly described as a palliative. In point of fact, there is nothing 
of the nature of a specific remedy which we are warranted in recom- 



XLIV.] TREATMENT. 717 

mending with any confidence, but it is proper that attention should be 
called to the sulphites and sulphurous acid, both of which have been 
strongly supported by some recent German writers ; and it is well to 
remember that, if the sulphites are freely employed, a purgative action, 
which we are desirous on other grounds of producing, will be induced. 
The cold water treatment, which has so undoubted an effect in reducing 
temperature, has received the support of Schroeder, but it is more 
than doubtful whether we would be justified in anticipating from this 
any more reliable effects than from the specific remedies hitherto 
suggested. 

Blisters to the abdomen have been thoroughly tried, but without any 
very satisfactory results. Among modern authorities, Dr. Churchill 
seems, however, to retain some belief in their efficacy, and says that, 
from the cases he has seen, he is "inclined to think blistering useful, 
and it affords an opportunity of applying mercurial ointment to a 
highly absorbent surface." Iodine has also been suggested, but the 
external applications which find most favor are either warm poultices 
or turpentine fomentations. 

The asthenic character which has been so generally observed in the 
more recent epidemics has led many, whose experience has been con- 
fined to cases of this type, to discard all treatment in favor of a stimu- 
lant and tonic regimen from the first. Dr. John Clarke gave bark in 
powder and decoction, with opium and wine. M. Beau found great 
benefit in the use of quinine in doses of fifteen to thirty grains in the 
day. Certainly, the results of free stimulation have been such as to 
warrant us in persevering, while life lingers, in the use of this, which 
is perhaps the most valuable class of remedies at our command. 

It has lately been proved by Mr. Spencer Wells that, in ovariotomy, 
benefit is derived by boldly tapping and withdrawing large quantities 
of turbid serum, in cases in which extreme effusion had come on in 
connection with other symptoms of septicaemia. It remains to be 
determined by the experience of the future, whether, by puncture from 
the vagina or in the abdominal walls, the withdrawal of similar effusions 
may, in puerperal fever, be attended with equally favorable results. 

The topical treatment of the most probable centres of septic infection 
must never be lost sight of. It is to be feared that the dread which 
attaches to this disease renders practitioners sometimes culpably timid 
in regard to the manipulation of the genital organs, and so duties are 
left absolutely to the nurse, which ought at least to have our careful 
supervision. If, in any case, foetor or any other abnormal symptom 
should arise in connection with the discharges, antiseptic injections are 
indicated ; and, if necessary, carbolic dressings should be applied to the 
lacerations, and even weak solutions of carbolic acid injected into the 
uterus. This, with the strictest attention to cleanliness, will go far to 
check or modify the progress of the disease. 

The question of prophylactic treatment, which naturally suggests 
itself here, is second in importance to no point relative to our subject. 
The rules of lying-in institutions are generally framed with the view 
of prohibiting students who are engaged in the dissecting-room from 
the practice of midwifery, or, at least, point to the strictest precautions 



718 PUERPERAL FEVER. [CHAP. 

being observed. The danger, however, is much greater from those who 
are engaged as dressers in hospitals where there is erysipelas or hospital 
gangrene. Improved ventilation has proved in hospitals an invaluable 
check on the ravages of the epidemic disease ; and there is good reason 
to believe that in some instances neglect of proper drainage has led to 
an aggravation of the type. The case of the General Lying-in Hos- 
pital, which was built on the marshy land by the Thames, affords an 
illustration of this, as after proper drainage the mortality in that insti- 
tution diminished in the most remarkable manner. Where there is 
the slightest reason to suspect the possibility of any zymotic influence, 
chlorine, Condy's fluid, or carbolic acid, should be freely employed, as 
there cannot be the slightest doubt that these agents tend to neutralize 
this or any other morbid poison. Large lying-in hospitals, as at present 
constructed, must be unhesitatingly condemned ; for great as are the 
educational advantages attached to such institutions, the cost in human 
life is too fearful to contemplate. The smaller establishments are more 
easily managed, and of late years show a rate of mortality which is, as 
compared with former experience, highly satisfactory. Still, much in 
this particular direction requires to be done before hospitals are freed 
from this one special danger, and it is more than probable, as we con- 
ceive, that this may ultimately be achieved by the cottage hospital plan, 
the great objection to which is, unfortunately, especially in large towns, 
its cost. 

It is impossible to exaggerate the importance, in its bearing upon 
prophylaxis, of the strictest attention to cleanliness on the part of the 
practitioner, who in an ordinary case should wash his hands not only 
after but before each examination. Such a precaution would no doubt 
be scrupulously observed had he just come from a case of scarlatina or 
erysipelas, or from a post-mortem examination ; but, the more com- 
pletely the doctrine of septic infection is established, the more clearly 
does it appear that the great majority of cases of puerperal fever are 
preventible, and, if so, we may be sure that to act, in every case, as if 
we had special reasons to fear that we might propagate the disease, is 
the surest Avay to reduce the risks to a minimum. For ordinary prac- 
tice, thorough cleansing with hot water and soap will suffice, and the 
nail-brush should also be used, as below and at the root of the nails are 
the situations in which septic matters are most likely to be retained. 
The precautions necessary, where we have any special cause for alarm, 
consist in a still stricter attention to cleansing the hands, and here, in 
addition to soap and water, Condy's fluid or carbolic acid should be 
employed. We must not, however, lose sight of the fact that the finger 
of the accoucheur is not the only possible conductor of the poison. 
Unless the nurse directly imports the poison, the fact of her attention 
being confined to one case at a time renders her less likely to infect a 
patient than a general practitioner who, in the course of a single day, 
supposing his obstetric practice to be quite free from fever, may have 
visited several cases of scarlatina, dressed a wounded limb affected with 
phlegmonous erysipelas, and performed a post-mortem examination. 
But, on the other hand, the nurse in the course of her special duties 
comes directly in contact with the discharges, so that there is no point 



XLV.] DIPHTHERIA OF PUERPERAL WOUNDS. 719 

of greater importance in the education of these women than the necessity 
of inculcating strict cleanliness in their own persons as well as in that 
of their patient. A weak solution of carbolic acid may be habitually 
employed. Again, the poison may very readily be conveyed by the 
dress, so that it should be changed where we have previously been in 
attendance upon a suspicious case. And, in like manner, the linen, 
napkins, and so forth, are possible vehicles of conveyance ; but this, 
for obvious reasons, is more likely to take place in hospital, than in 
private practice. 

It has frequently happened that no cleansing, or disinfection, or 
change of dress, has had any effect in checking a series of fatal cases in 
the practice of the same person, so that no alternative remains but to 
withdraw absolutely from practice for six weeks or more. Does this 
not show that there are other modes of communication ? If we are 
right in supposing that transmission, even of a septic poison, is possible 
through the medium of the atmosphere, may we not assume that, in 
cases of great virulence or concentration of the poison, the system of 
the accoucheur may become impregnated with the poison, and that, 
although harmless to him, it may again be given off by the lungs or by 
the skin. It is true that disease germs have never been seen or traced 
through the air ; but practice founded on this belief has, in the hands 
of Lister and his pupils, been attended with brilliant resul s. It is too 
much to hope that one day, by a process of antiseptic delivery, the 
fearful danger of this poison may, even in hospital practice, be reduced 
within narrow bounds, to the benefit of humanity, and the lasting credit 
of modern science. 



[CHAPTEE XLV. 

DIPHTHEKIA OF PUERPEKAL WOUNDS. 

PREVALENCE DURING THE PAST FIVE YEARS — SYMPTOMS I THOSE WHICH PRECEDE 
THE OUTBREAK: THE DIGESTIVE SYSTEM: PAIN AND ABDOMINAL TENDER- 
NESS : PULSE AND RESPIRATION : TEMPERATURE : COUNTENANCE I MENTAL 
CONDITION: LOCAL SYMPTOxMS — FALSE MEMBRANE ON WOUNDS — JOINT COM- 
PLICATIONS — DIAGNOSIS AND PROGNOSIS — PATHOLOGICAL ANATOMY — NATURE 

— CAUSES — treatment: quinia : opium: local remedies: cauterization 

OE DIPHTHERITIC "WOUNDS: VAGINAL AND INTRA- UTERINE INJECTIONS: 
PROPHYLAXIS. 

This is a disease of the puerperal state which is not alluded to by 
the author. The first American writer who described it, so far as we 
are aware, was Professor Fordyce Barker, who directed the attention 
of the Obstetric Section of the New York Academy of Medicine to the 
subject, in 1860 and 1861. Speigelberg and Schroeder also allude to 
the presence of false membrane on genital wounds in some cases. Pro- 
fessor Edward Martin, of Berlin, believes that diphtheritic deposits on 



720 ' DIPHTHERIA OF PUERPERAL WOUNDS. [CHAP. 

wounded surfaces of the genital organs, " is the only essential element 
of puerperal fever." This affection has recently acquired a new interest 
and importance in this country. Since the early part of the year 1870, 
the editor has seen many cases of the disease. During the past five 
years it has prevailed more or less extensively throughout various parts 
of the country, and in the hospitals of some of our large cities. Between 
February 7th, 1870, and July 1st, 1874, about one hundred cases of 
this disease occurred in the obstetrical wards of the Philadelphia Hos- 
pital, of which, twenty-five per cent, were fatal. We have already 
published a history of the outbreak in the American Journal of the 
Medical Sciences for January, 1875, from which this account of the 
disease is condensed. 

Symptoms. — The disease may set in suddenly or be preceded by 
certain premonitory symptoms. Among the latter are pelvic pain and 
uneasiness, usually supposed to be after-pains by the patient. This 
pain is at times associated with swelling and relaxation of the uterus, 
and a peculiar sunken, pale countenance, which continues throughout 
the disease. The last is a most important symptom when it occurs. 
Indeed we believe it to be the most significant of the phenomena which 
are likely to be noticed before the outbreak of the disease. Pelvic 
pain, tenderness, and enlargement of the uterus may be due to other 
and temporary causes, but this change of the countenance, which will 
be more fully described in the appropriate place, indicates that a potent 
poison has already entered the blood, and commenced its destructive 
work. The symptom is withal very characteristic, and more than once 
it has been the first thing which has excited our alarm on entering the 
chambers of our patients, or the wards of the hospital. These symp- 
toms may exist for twelve or eighteen hours before the disease fairly 
explodes. 

If these premonitory symptoms are absent, the disease sets in suddenly 
at the end of the first or during the second, but rarely later than the 
third day after delivery. It may commence with a well-marked chill 
or a rigor. The latter is the more common, though even this is some- 
times absent. The woman rarely has a severe chill. Succeeding this 
cold stage is a hot one, in which the febrile reaction is high. In the 
early stages the skin is hot and dry. Later, after two, three, or four 
days, it becomes moist, the perspiration appearing at irregular intervals. 
The heat of the skin during the first few days is very great. Calor 
mordax may be as marked as it is in scarlet, typhus, or relapsing fevers. 
Later, a marked elevation of temperature is not revealed by the touch. 

The digestive system is always more or less disturbed. In the early 
stages the tongue is covered with a white or yellowish-white fur. This 
sometimes disappears quickly, and in flakes, leaving the organ red, 
smooth, and dry, in the centre. In some cases the margins are red 
and clean, with a clean triangular space at the tip. During the last 
stages of the disease the tongue may become dry, and covered with 
sordes. This is nearly always its condition in fatal cases. The appe- 
tite is almost always destroyed, though many women suffering from 
this disease will take all the food which is offered to them. Vomiting 
is a frequent though not a constant symptom. The ejected matters are 



XLV.J SYMPTOMS. 721 

often of a bright-green color. The bowels are generally constipated. 
Diarrhoea is rare, except in fatal cases. The abdomen is distended 
with gas. The degree of distension is sometimes extreme, especially 
when death is about to occur, when it may materially impede respira- 
tion. The abdomen is generally tender. This tenderness usually 
begins in one or both iliac fossae, and extends upwards till nearly all 
the abdominal surface is involved. 

The patient rarely complains of much pain in the abdominal and 
pelvic cavities. When asked to take a deep breath, she usually mani- 
fests more or less uneasiness. The severity of the pain and the degree 
of tenderness bear no proportion whatever to the extent and intensity 
of the inflammation of the peritoneum. The most extensive and severe 
peritonitis may exist, and yet the patient manifest little or no uneasiness 
when the abdomen is firmly and even rudely manipulated. This has 
been repeatedly observed in fatal cases, in which the post-mortem 
examination revealed the existence of the most severe and extensive 
inflammation of the peritoneum. In other cases the pain may be severe, 
and the abdomen exquisitely sensitive to pressure. These symptoms 
are rare, however. It is very seldom that complaint is made of the 
weight of the bed-clothes, and the decubitus is nearly always on the 
back with the limbs fully extended. 

The pulse during the first twenty-four hours is full and round, but 
rather compressible. It is never small, hard, and corded, as it is in 
acute sthenic non-septic peritonitis. It quickly runs up to 120, 130, 
or 140 per minute, and we have seen it as high as 170 on the third 
day after confinement. In a few days it becomes very frequent, Aveak, ■ 
and compressible, as in all typhoid diseases. Throbbing of the carotid 
and the other large arteries which are superficial in their position,, is a 
frequent symptom. 

The respirations are frequent, and the patients usually complain of 
pain in the abdomen and pelvis upon taking a full inspiration. In 
fatal cases, as death approaches, breathing is often greatly interfered 
with, and rendered singultiform by the extreme tympany. In the 
majority of the cases the disease runs its course without any pulmonary 
complication, but acute pleurisy and pneumonia are not rare, and may 
set in at any time after the third or fourth day of the disease. The 
pleurisy is generally bilateral. It is often latent, and hence the con- 
dition of the lungs should always be carefully watched in this disease. 
In rare cases the symptoms of pleuritic inflammation may completely 
mask those of the peritonitis. 

The temperature ascends abruptly at the outset of this disease, and 
reaches 104° or 105° Fahr. in a few hours. This sudden elevation is fol- 
lowed in one or two days by a decline in which the body heat approaches 
more or less nearly to the normal standard, but does not reach it. This 
decline occurs in both favorable and fatal cases. It does not afford the 
slightest ground for a favorable prognosis. In fatal cases there may 
be a regular and apparently a favorable decline of temperature for one, 
two, or three days before death. Unless this diminution of the body 
heat is associated with corresponding favorable changes in the pulse, 
respirations, and appearance of the patient, it indicates that the disease 

46 



722 DIPHTHERIA OF PUERPERAL WOUNDS. [CHAP. 

will rapidly run on to a fatal issue. In favorable cases one of the first 
indications of the approach of convalescence is an increase in the morn- 
ing remission, which continues to become more marked from day to 
day. The diagrammatic representation of the variations of the tem- 
perature consequently sometimes has the appearance of that produced 
by a quotidian intermittent fever. After these diurnal variations have 
become marked, when they vary from 3° to 6° Fahr., there is some- 
times a tendency for the morning temperature to fall below the nor- 
mal standard. We have seen it as low as 95° Fahr. This decline is 
attended with profound collapse. The only discharge which accom- 
panies it is a profuse perspiration. Sudden fall of temperature and 
collapse are exceptional rather than constant phenomena of the disease. 
In all cases in which we observed them the patients recovered. When 
convalescence is retarded by suppuration in the abdominal or pelvic 
cavities, the normal temperature may not be regained until the ninth 
or tenth week of the disease. Under these circumstances the ther- 
mometer furnishes the most reliable indications of the danger of the 
patient, which has not passed until the temperature has regained the 
normal standard. 

The expression of the countenance is peculiar and characteristic. As 
the changes in the physiognomy of the patient frequently precede the 
constitutional symptoms, they are of considerable diagnostic value. 
Either before or after the initial chill, the features assume a shrunken 
appearance, the eyes, which are surrounded by livid, dark-colored 
areola?, recede in their sockets ; the nose becomes pale, pinched, and 
sharp ; the lips are thin, and the skin of the face has somewhat the 
color and appearance of parchment. As the patient is nearly always 
cheerful and happy, her smiles under these circumstances give her a 
weird, ghastly expression of countenance, which cannot be readily foj*- 
>gotten. 

More or less delirium occurs in fatal cases before death. It is of the 
low muttering variety that is met with in other typhoid diseases. Vio- 
lent maniacal delirium may occur at the outset, but this is rare. The 
mental condition which is characteristic of the affection, is an utter in- 
ability on the part of the patient to appreciate her condition. She does 
not believe herself to be ill, but at each visit receives her medical attend- 
ant with a smile, and the confident assurance that she is perfectly well. 
If she recovers she appears to be unaware that she has been seriously 
ill. If the issue is fatal, death steals on her, and the woman makes no 
sign that she knows the solemn change is at hand. This mental con- 
dition is one of the saddest and strangest we have ever witnessed. 

The symptoms connected with the genital organs are of the highest 
importance. The appearance of a yellowish ash-colored diphtheritic 
false membrane upon wounds of the perineum, fourchette, vagina, 
and cervix is the characteristic local phenomenon of the disease. The 
slightest injury of any one of these parts during labor is followed by 
the formation of this membrane upon its surface. It never makes 
its appearance upon uninjured tissues in the first instance, though it 
may spread to these during the progress of the disease. It may line 
the whole vaginal canal and interior of the uterus, and we have found 



XLV.] DIAGNOSIS — PROGNOSIS. 723 

it on an inflamed surface of the mucous membrane of the descending 
colon. This diphtheritic formation varies from a mere film to a thick, 
tough, tenacious false membrane. The parts upon which it appears 
sometimes ulcerate rapidly, as though the membrane had an erosive 
or dissolving action on the tissues. In from two to ten days the diph- 
theritic formation separates, leaving an ulcer which heals slowly by 
granulations if the disease is not fatal. 

Diphtheritic deposit may make its appearance on wounds of the 
genital organs before the initial chill or rigor occurs, but in these cases 
it is associated with shrinking of the features, pallor of the face, pelvic 
pain, and swelling of the uterus. 

The false membrane which has been described is, without doubt, 
diphtheritic in its nature. Prof. Lusk, who witnessed an outbreak of 
this disease at Bellevue Hospital, in New York, says that Dr. Steurer, 
who was one of his internes during the epidemic, has recently studied 
the microscopical appearances of this membrane in connection with 
Prof. Yon Recklinghausen, of Strasburg. Dr. Steurer says, "We 
found it a true diphtheria. Micrococci were found beneath the deposit 
and scattered throughout the tissues of the uterus, whence they were 
taken up by the sinuses, and conveyed into the circulatory system. 
They may be found in the muscular structure of the vulva, and always 
occur in colonies. They are sometimes found in the bloodvessels of 
the kidney, distending whole glomeruli." 

The lochia may be diminished or entirely suppressed. When per- 
sistent they may be more or less offensive. The uterus becomes en- 
larged. This appears to be due to swelling rather than relaxation. 
The enlargement may be so great that it is difficult to believe that the 
organ is empty. This symptom appears with the pelvic pain, and may 
precede the chill or rigor. 

Inflammation of the joints must be noted among the local symptoms. 
This may come on any time from the third to the twelfth day. Any 
of the joints may be affected. The process is identical in its nature 
with that which occurs in surgical pyaemia. 

The most important results of the disease are inflammatory indura- 
tions and purulent accumulations in the pelvic and abdominal cavities. 
These are detected after the acute symptoms have disappeared, by com- 
bined vaginal and abdominal examination. The abscesses may open 
into the vagina, bowel, or through the abdominal wall, and they some- 
times give exit to enormous accumulations of pus. 

Diagnosis. — This is not difficult. The presence of a diphtheritic 
false membrane on an injured surface of the genital tract sets all doubts 
at rest. 

Prognosis. — This should be guarded. The establishment of marked 
morning remissions of temperature is a favorable sign. Fall of tem- 
perature without corresponding favorable changes in the pulse, respira- 
tions, and appearance of the patient, presages death. Obstinate diar- 
rhoea is an unfavorable symptom. 

Pathological Anatomy. — If death occurs during the early stages of 
the disease, injured surfaces and adjoining parts of the genital organs 
are found covered with the diphtheritic false membrane which has 



724 DIPHTHERIA OF PUERPERAL WOUNDS. [CHAP. 

been described in connection with the symptoms of the disease. If 
life is prolonged for several days, the false membrane may have sepa- 
rated, leaving unhealthy, dark-colored, sloughing ulcers. Starting 
from these lesions of the fourchette, vagina, or cervix, and having its 
origin in them, is a pathological change of the highest importance. 
This is inflammation of the connective tissue. Beginning at the 
wound, it extends upwards till it involves the whole of the pelvic and 
much of the subperitoneal connective tissue, which becomes infil- 
trated with a gelatinous substance, which may be transparent or stained 
with the coloring matters of the blood. Mingled with this substance 
are cell-elements, which have their origin in differentiation of the con- 
nective-tissue corpuscles and the migrated white blood-corpuscles. 

At those points in the pelvis where the cell-elements are produced 
rapidly and profusely, there is perceptible swelling, which formed the 
pelvic tumors discoverable during life by vaginal examination. These 
inflammatory indurations are most frequent in the broad ligaments, at 
the sides of the pelvis, in contact with the bones, and low down upon 
either side of the cervix uteri. In size they may vary from mere 
points to masses as large as an orange. The appearances presented by 
a section of these inflammatory swellings vary with the duration of the 
disease before death. In the early stages they have a somewhat irreg- 
ular nodular outline, and are more or less firm to the touch. The cut 
surface in the first stage is red, with yellowish points, such as are found 
in other phlegmonous inflammations, scattered here and there. When 
the disease has progressed farther, and suppuration has occurred,, the 
swellings are converted into abscesses. 

In a number of cases inflammation of the connective tissue extends 
outwardly from the pelvis, and involves the anterior surface of the 
thigh. This may lead to obstruction of the veins and lymphatic ves- 
sels by thrombi, and the production of phlegmasia dolens. 

The inflammation and swelling of the connective tissue of the pelvis 
likewise frequently lead to thrombosis and occlusion of the veins and 
lymphatic vessels of the part. These often appear as prominent lesions 
at the autopsy, and consequently undue importance is liable to be at- 
tached to them in this, as has been done in other puerperal diseases. 
Virchow has directed attention to the fact that thrombosis of the lym- 
phatics is a conservative and not a destructive change. 

The uterus is nearly always large and flabby. Its interior may be 
covered with diphtheritic false membrane. There is generally more or 
less endometritis, while the walls of the organ are thickened from swell- 
ing and inflammation. 

The peritoneal covering of the Fallopian tubes is generally intensely 
inflamed when peritonitis complicates the case. The mucous mem- 
brane is injected and covered with bloody mucus. The fimbriated 
extremity may be occluded, after which the products of inflammation 
may accumulate in its cavity in considerable quantities. 

The ovaries are much less likely than the tubes to escape the effects 
of the disease. Their anatomical position is such that inflammatory 
action readily extends to them from the connective tissue of the broad 
ligament. The result is that they may be almost entirely destroyed by 



XL V.] NATURE. 725 

inflammation and suppuration, even when the Fallopian tubes are but 
slightly affected by disease. 

The other lesions of this disease are those of septic affections in gen- 
eral, so that it is not necessary to occupy additional space in their de- 
scription. The peritoneum, pleura, and pericardium may be extensively 
inflamed, and one or more joints may be completely disorganized, but 
these changes, though they may overshadow and obscure other anatomi- 
cal alterations, are not an essential part of the disease. The character- 
istic anatomical alterations of this affection are the formation of a diph- 
theritic false membrane upon wounded surfaces, and inflammation of 
the pelvic and subperitoneal connective tissue. 

Nature. — This disease is closely allied to pysemia. The two resemble 
each other in their liability to joint complications, the formation of 
thrombi, to alterations of temperature, and in other symptoms. It 
differs from pysemia and septicaemia, however, in the constant presence 
of diphtheritic deposit on wounded surfaces. It is probably analogous 
or identical with the " diphtheria of wounds/' or hospital gangrene, 
described by Billroth (Surgical Pathology, p. 308). 

It is possibly due to the absorption of a septic poison by an injured sur- 
face, but there is some reason for believing that it may be parasitic in its 
origin. In order for the poison to enter the system, some channel must 
be opened for its admission. Unfortunately every woman is more or less 
injured during labor. It is admitted by the highest authorities that 
septic matter, when it enters the system by an injured surface, produces 
two effects, high febrile reaction and inflammation of the tissues with 
which it comes in contact, whether it reaches them directly or- through 
the medium of the blood. If these opinions are correct, the pathologi- 
cal appearances become perfectly intelligible. The process is at first 
entirely local. The materies morbi of the disease produces inflammation 
of the surface injured during labor. This is followed by the produc- 
tion of a false membrane, which is as important a feature of the dis- 
ease as the ash-colored leathery formation is in the throat in diphtheria. 

If the inflammation stopped here it would be well for the patient, 
but from this point it extends in various directions, affecting the con- 
nective tissue, and through this involving other structures, the veins, 
lymphatics, ovaries, and peritoneum. At the same time the morbific 
matter to which the diphtheritic changes in the wound owed their 
origin is being reproduced in large quantities in the inflamed areas. It 
enters the blood, producing high febrile reaction and inflammation in 
organs which are remote from the locality in which the process had its 
origin. 

Peritonitis has always been assigned a prominent place in the dis- 
cussion of the pathological appearances of " puerperal fever." In 
"diphtheria of wounds" and all the class of diseases to which it be- 
longs there is every reason to believe that it occupies a subordinate 
position. Though the inflammation may be so intense and extensive 
as to overshadow all other anatomical alterations, it is but an effect of 
the disease, and not the disease itself. In the affection which is being 
described, and in pyaemia and septicaemia, when the poison of the dis- 
ease has accumulated to a certain extent in the circulating fluid, it may 



726 DIPHTHERIA OF PUERPERAL WOUNDS. [CHAP. 

produce inflammation of any tissue with which it comes in contact. The 
serous membranes are peculiarly susceptible to its influence, and hence 
peritonitis, pleuritis, and pericarditis are common effects of the entrance 
of septic matter into the system. 

That peritonitis is not always due to the extension of inflammation 
from the pelvic connective tissue upwards is proved by the fact that 
the inferior portion of the membrane may escape, while that part of it 
which lines the upper portion of the abdominal cavity may have un- 
dergone the most severe changes. The editor has seen the peritoneum 
of the pelvis and lower part of the cavity of the belly almost unaltered, 
while the spleen, liver, and stomach were literally buried in lymph. 

While the pleurisy of this disease may be due to extension of inflam- 
mation upwards through the diaphragm, this is not its universal origin. 
The fact that it may occur when the peritoneum of the upper part of 
the cavity remains healthy proves this, while the fact that the disease 
is bilateral is an indication of its constitutional origin. 

The opinion that diphtheria of puerperal wounds is at first a local 
disease, appears to be sustained by the clinical history of the affection, 
as well as by its pathological appearances. The local symptoms, the 
diphtheritic membrane, evidences of pelvic inflammation, and swelling 
of the uterus precede the symptoms of constitutional reaction several 
hours. Even the appearance of the countenance may be materially and 
characteristically altered before the occurrence of the initial chill and 
the fever which follow it. The effects of the poison which has entered 
the blood can be distinctly traced in the local inflammation of the in- 
jured surfaces and the connective tissue of the pelvis before it has had 
time to produce constitutional reaction, or before the amount of septic or 
parasitic matter in the circulating fluid is sufficient to give rise to fever. 

Causes. — For the production of this disease it is necessary for the puer- 
peral woman to be brought in contact with virus of the disease, and that 
she should present an injured surface capable of absorbing it. There is 
reason to believe that the poisons of pyaemia, septicaemia, and diphtheria 
of wounds do not enter the system by the skin, lungs, and intestinal 
canal, but find their way into the blood by a wound, which must be either 
fresh or have had the granulations on its surface destroyed if they pre- 
viously existed. Billroth has shown that a healthy granulating surface 
will not absorb septic matter. These expressions indicate the impor- 
tance of traumatism in the production of the disease. 

The disease may be autogenetic or heterogenetic in its origin. In 
the second class of cases, the poison may be derived from the atmosphere, 
or the woman may be inoculated with it by her accoucheur, or nurse, 
or by the use of soiled clothing, sponges, or towels. While it is impossi- 
ble not to recognize the fact that this affection is inoculable or manu- 
ally contagious as syphilis and vaccine diseases are, we know of no 
facts which prove that it is contagious, in the widest sense in which that 
term is used. A large experience has apparently shown that it is not 
reproduced as variola, typhus and relapsing fevers are. The whole 
difference may be summed up by saying that the channels by which 
the disease germs enter the system, are not the same in the two classes of 
cases. It is a demonstrated fact that the seeds of variola may gain access 



XLV.] TREATMENT. 727 

to the circulation by more than one avenue. It is probable that the 
same is true of typhus fever and other diseases of its class. The poisons 
of syphilis and vaccine disease can only be transmitted by a wound. 
Clinical observations appear to warrant the conclusion that the same is 
true of the poison of this disease. 

Diphtheria of wounds is not a disease peculiar to hospitals. We have 
recently met with it in a number of patients whose means enabled them 
to command every comfort, and under circumstances in which every 
possible source of contagion was removed. We have seen it make its 
appearance in a remote rural district, hundreds of miles from any large 
city, and where it could not possibly have been due to contagion. The 
accoucheur, in this case, had been in ill-health for some time and had 
not seen a case of septic disease or attended a woman in labor for more 
than six months. It cannot be denied, however, that the wards of a 
hospital in which this disease makes its appearance, may become con- 
taminated and unfit to be occupied by puerperal patients. In this, 
the disorder does not differ from pyaemia, septicaemia, and hospital 
gangrene in surgical wards. 

Treatment. — There is no internal remedy which is a specific for this 
disease. Immediately after the initial symptoms make their appearance, 
the patient may be given simple fever mixtures of sweet spirits of nitre, 
and the solution of acetate of ammonia, and neutral mixture. Veratrum 
viride cannot be resorted to. The disease is asthenic in its type and 
veratrum does not reduce the frequency of the pulse of debility. 

Quinia is recommended by many authorities in the treatment of dis- 
eases of this class. From ten to twenty-five grains should be pre- 
scribed daily, in two doses, one in the morning and the other in the 
evening. This method of giving the remedy appears to be followed by 
better results than the administration of small doses at short intervals. 
Large doses of this drug are sometimes followed by a- temporary fall 
of temperature, but it is difficult to decide whether this is due to the 
medicine or not. The comparison of the records of the temperature 
of a number of cases in which quinia was given, with those of others 
who did not take it, shows that it is unsafe at present to attribute to 
quinia any power to reduce the heat of the body in this disease. 

As peritonitis is one of the most common results of the absorption of 
the virus of this disease, the treatment must be largely directed to the 
relief of the symptoms of this complication. For this purpose, opium, 
or some of its preparations, is the most valuable remedy. It should be 
given as in acute peritonitis, until pain is relieved, and the patient is 
made comfortable. In bad cases this does not occur until the woman 
is semi-narcotized. The quantity administered should be limited only 
by the effect produced. It is sometimes necessary to give a grain, or 
even much more of morphia in solution, at short intervals. In these 
cases, the improvement that follows the bold use of narcotics is some- 
times very surprising. 

The use of the sulphites and hyposulphites has not been followed 
by any good results in our hands. Large doses of the tincture of the 
chloride of iron seemed to irritate the stomach. Carbolic acid likewise 
disordered the stomach, and appearred to produce diarrhoea. 



728 DIPHTHERIA OF PUERPERAL WOUNDS. [CHAP. 

The nourishment of the patient is a point of the highest importance. 
Good food should be given from the outset, and stimulants should be 
administered if required. 

Purgatives are injurious, except when specially indicated. Local 
depletion by leeches is dangerous, not only because it produces depres- 
sion, but because it may be difficult -to arrest the hemorrhage from the 
bites. 

Local Treatment. — Turpentine stupes should be applied to the abdo- 
men as soon as the woman begins to complain of pain. These may be 
followed by warm applications covered with oiled silk. 

The most important question in connection with the local treatment 
concerns the management of the diphtheritic ulcers. This will have 
to be decided by future experience. Local applications are rarely called 
for to prevent sloughing. If of use it is to prevent the absorption of 
septic matter, and the growth of micrococci at first, and afterwards to 
aid the process of repair. The wounds are often very difficult to detect 
if situated high up in the vagina or on the cervix uteri, and it is very 
questionable whether the physician is justified in introducing a specu- 
lum, to seek for them when the tissues about the vulva and perineum 
are found to be healthy on inspection. 

We have employed local applications of carbolic acid and Monsel's 
solution under these circumstances, but have never felt satisfied that 
they were beneficial. Speaking of this matter, Professor Lusk says, 
" In my own experience, prompt cauterization with strong carbolic 
acid or the application of Churchill's tincture to the diphtheritic mem- 
brane, was often followed by a surprising amelioration of the symptoms, 
which had assumed an alarming character." In the latter portion of 
the same interesting and highly important paper, Dr. Lusk adds that 
after the wards at Bellevue Hospital had become thoroughly poisoned 
by the "miasm" of this disease, "cauterization of the local lesions 
ceased to possess any marked efficacy." 1 This probably explains why 
the writer obtained no benefit from their use. He did not employ either 
carbolic acid or the solution of the subsulphate of iron, at the outbreak 
of the disease, as he did not at the time appreciate the importance of 
the appearance of false membrane upon wounded surfaces. After the 
disease had become firmly fixed in the wards of the Philadelphia Hos- 
pital, their use certainly produced little if any amelioration of the 
symptoms. 

Dr. Lusk's experience would appear to warrant the inference that 
we may hope for much benefit from these remedies in sporadic cases, 
occurring in hospitals and in private practice. 

Injections, both vaginal and intra-uterine, have been recommended in 
diseases of this class. Offensive lochia would appear to be a positive 
indication for their use, but we have not derived that benefit which we 
anticipated from their use. It is important to remove any decompos- 
ing matter from the vagina, yet it must be remembered that when the 
disease commences at the fourchette and low down in the posterior wall 

1 The Genesis of an Epidemic of Puerperal Fever. Amer. Journ. of Obstet., 
November, 1875. 



XLV.] PROPHYLAXIS. 729 

of the vagina, the tube of the syringe may carry the virus to the lesions 
of the cervix, and thus set up a new focus, through which the contami- 
nation of the blood may be increased. Reasoning and clinical expe- 
rience have therefore led us to employ vaginal injections somewhat 
charily in this disease, but they ought not to be absolutely condemned. 
An offensive and copious vaginal discharge indicates their use. 

Intra-uterine injections are more dangerous than vaginal, and, in the 
cases in which we have used them, they have done harm with few ex- 
ceptions. They often produce pain, and their use may be followed by 
an increase of fever and abdominal uneasiness. 

Though there is still uncertainty about the usefulness of caustics 
applied to the genital wounds, and of intra-uterine injections, the 
medical attendant is not without resources. The diphtheritic ulcers 
need careful treatment. They heal slowly at best. They are to be 
managed on general principles. A stimulating local treatment is gen- 
erally required. Cleanliness cannot be too carefully observed, and in 
a hospital every patient should have her own basin, towels, and sponges. 
In place of the last, however, it is better to use oakum or some other 
substance that can be thrown away after it has been soiled. 

Prophylaxis. — The means by which inoculation may be prevented 
need not be alluded to here. During labor it is important to make as 
few vaginal examinations as is consistent with the safety of the patient. 
The placenta should be delivered by Credos method. 

Whether cauterization of such wounds as may be visible immediately 
after delivery will prevent the disease, has not been determined by 
clinical experience. The measure is certainly worth a trial. Nitrate 
of silver, nitric acid, or bromine, might be used. 

We know of no drugs which have any influence in preventing the 
disease. Large doses of quinia, tincture of the chloride of iron, and 
various other medicines were tried in the Philadelphia Hospital without 
avail. The only s'ure prophylactic is to remove the woman from an 
infected atmosphere before labor sets in. — P.] 



730 PELVI-PERITONITIS. [CHAP. 



CHAPTER XLVL 

PELYI-PERITONITIS : SUDDEN DEATH IN PUERPERAL 
PERIOD: ANAESTHESIA. 

PELVI-PERITONITIS — INFLAMMATION OF THE UTERINE APPENDAGES — " FULNESS," 
"HARDNESS," AND " TUMOR " — PELVIC CELLULITIS: ANATOMY OF THE 
PELVIC CELLULAR TISSUE — BERNUTZ ON PELVI-PERITONITIS — DIAGNOSIS OF 
PELVIC CELLULITIS AND PELVI-PERITONITIS — ENGORGEMENT OF THE UTERUS 
— DETECTION OF PUS: FLUCTUATION — TREATMENT: ALLEVIATION OF PAIN: 
APPLICATION OF LEECHES, POULTICES, FOMENTATIONS, ETC. : METHODS OF 
PROMOTING ABSORPTION; MERCURY; IODINE; COUNTER-IRRITATION: THE 
OPERATIVE TREATMENT OF ABSCESS — PERI-UTERINE HEMATOCELE — SUDDEN 
DEATH IN PUERPERAL PERIOD : EMBOLISM OF PULMONARY ARTERY — ARTERIAL 
EMBOLISM — ENTRANCE OF AIR INTO VEINS — ANAESTHESIA: VARIOUS ANES- 
THETIC AGENTS : EFFECTS OF CHLOROFORM ON THE BLOOD AND ON THE PROG- 
RESS OF LABOR : DISADVANTAGES OF CHLOROFORM : MODERN PRACTICE. 

In addition to the diseases which have been grouped together in the 
two preceding chapters, under the common designation of puerperal 
fever, there are other affections, chronic for the most part in their nature, 
which require some notice at our hands. These are by no means nec- 
essarily associated with the puerperal state, although about a half of all 
cases have their origin in inflammatory processes which arise, more or 
less distinctly, from the condition under which women remain for a 
certain period after delivery. The connection between the disorders 
which we are about to describe and puerperal fever is, in some cases, 
direct and unmistakable; but, in the great majority of instances, the 
disease, although inflammatory in its nature, has no such intimate rela- 
tion to puerperal fever as to admit of its being placed in the same cate- 
gory. For these and other reasons, it is thought better to consider the 
group of affections to which we have referred as separate from, although 
associated with, those previously described. 

In most systematic works, even by those w r hose merit is universally 
recognized, these affections are dismissed with a brief notice, and under 
a great variety of names. The first difficulty, therefore, which we en- 
counter, is in the matter of nomenclature — Pelvi- peritonitis, pelvic cellu- 
litis, subperitoneal inflammation, peri-uterine phlegmon, perimetritis, 
parametritis, and inflammation of the uterine appendages, are only a few 
of the many designations under which this group of affections have 
been described. They may be most usefully considered together, for 
purposes of analysis and such description as is here possible. A very 
brief preliminary definition of the various terms above employed is, 
however, essential. 



XLVI.] PELVIC CELLULITIS. 731 

What was originally described by M. ~Nonat as peri-uterine phlegmon, 
is better known to English readers under the more familiar designation 
of pelvic cellulitis, with which we may assume it to be almost synony- 
mous. The idea involved is an inflammatory affection, tending to the 
formation of abscess, which has its seat in the cellular tissue between the 
uterus and peritoneum, or in some other part of the same tissue within 
the pelvis. Both expressions are unfortunate, and involve a funda- 
mental error. Subperitoneal inflammation is another synonym equally 
objectionable. That inflammation of the uterine appendages is very com- 
monly associated with the class of affections which we shall describe is 
universally admitted ; but if used as a comprehensive designation, as 
Churchill has employed it, it may be supposed — and if so, very erro- 
neously — to be confined to these tissues. 

Dr. Matthews Duncan, who has treated the subject in his well-known 
work at considerable length, and with his usual ability, adopts the 
words parametritis and perimetritis, borrowing the idea of this nomen- 
clature, as he tells us, from Virchow, who, taking example from the 
heart and other organs, proposes to use peri to signify inflammation of 
serous membrane, and para to imply inflammation of cellular or con- 
nective tissue. "Perimetritis, then," he adds, "will strictly imply in- 
flammation of the uterine peritoneum. Parametritis will imply inflam- 
mation of the cellular tissue in connection with the uterus. Similar 
terms may be found for the Fallopian tubes, perisalpingitis and para- 
salpingitis, and likewise for the ovaries. But I shall seldom have occa- 
sion to resort to them. In the present imperfect state of our diagnostic 
resources, it would be mere pedantry to do so frequently. There are 
only a few cases in which we can assert, during life at least, that the 
pelvic peritonitis is parasalpingitis, or perioophoritis, or that the pelvic 
cellulitis is parametritis, parasalpingitis, or paraoophoritis. To hide 
our ignorance on this point, it would be convenient if we had a rough 
word expressing the internal genital organs, to which to prefix the ad- 
verbs 'peri' and 'para/ But we have not such a word, and I shall 
therefore, in accordance with old custom, give the uterus the prece- 
dence, and use terms compounded of it, as perimetritis, parametritis, 
etc., without always implying, by such use, a meaning exclusively and 
properly uterine, but implicating also the tubes and ovaries. I shall, 
indeed, use the words perimetric inflammation and perimetritis, parametric 
inflammation and parametritis, with a still wider meaning, implying in- 
flammations which directly owe their origin to disease or injury of the 
uterus, tubes, or ovaries. For example, a lumbar abscess, or an iliac 
abscess, may be perimetric or parametric in origin, although lumbar or 
iliac in mere situation." 

Pelvi-peritonitis, again, is the name to which a preference is given by 
Bernutz, and which is used by him in a sense precisely similar to that 
which Dr. Duncan has attached to his term " Perimetritis." There is 
very little in a mere name after all ; but if we were to select the one 
which is least likely to lead to misapprehension, we would be inclined 
to select pelvi-peritonitis, as indicating a limited peritoneal inflamma- 
tion, involving that portion of the membrane which invests the uterus, 
or other generative organs, and often causing adhesive matting together 



732 PELVI-PERITONITIS. [CHAP. 

of various parts, and the formation of tumors, which may be discovered 
both from the brim of the pelvis and from the vagina. 

If we read in most standard works, an account of what is usually 
called Pelvic Cellulitis, it would seem at first as if the subject were 
exhausted, and placed on a basis which nothing could shake. All 
tumors, abscesses, and inflammations in the pelvic region were regarded 
in the light of this simple pathology, that an inflammation in the sub- 
peritoneal cellular tissue represented the proximate cause of the disease 
in almost every case. No one, however, who carefully observes such 
facts as may come practically under his observation, or who even takes 
the trouble to analyze the obstetrical and gynceco logical records of the 
last few years, can fail to come to the conclusion that, so far from the 
subject being finally disposed of, it would be more correct to say that 
it is still in its infancy. And the more vigorously did he pursue his 
investigation, the more clear would it become that there lies here a field 
of study which is of deep interest, and of much promise. 

From the results which have been disclosed by post-mortem examina- 
tions, it is certain that the uterine appendages are not unfrequently the 
seat of inflammation, varying in degree and in extent ; the action, in 
some instances, being confined to the peritoneal coat, and in others 
extending more deeply, so as to involve the entire thickness of the 
Fallopian tube on the side affected. If the ovary is the seat of the 
disease, the result may, in like manner, be displayed, either on the 
surface of the organ, or, — should the action have reached more deeply, 
or have originated there, — the stroma may be found extensively dis- 
organized, and occupied with abscesses varying in size. Such serious 
disorganization may at any time result from an extension of the 
destructive inflammation so characteristic of puerperal peritonitis ; but, 
in the cases now under consideration, the symptoms are generally more 
chronic from the first, and are often looked upon, in reference to other 
coexisting phenomena, as merely secondary. It can be no easy matter, 
therefore, to determine where the disease has had its origin. The 
symptoms of inflammation of the uterine appendages are almost always 
very obscure. When the pain is circumscribed by limited peritoneal 
inflammation-, its site in the iliac fossa, or lateral region of the hypo- 
gaster, may be held to indicate a probability that the structures in 
question are affected ; but there are no reliable means for determining 
whether the morbid action is limited to the peritoneum and subjacent 
tissue, or extends further, so as to involve the deepseated structures of 
the tube or ovary. 

The diagnosis of these affections depends, in a great measure, upon 
the results of abdominal palpation and vaginal examination; and, from 
the many fallacies which may spring in the course of such an investiga- 
tion, it may be added, that upon the special experience of the examiner 
the accuracy of any opinion which may be formed will greatly depend. 
Dr. Matthews Duncan directs attention, at considerable length, and 
with much propriety, to the loose manner in which the expressions, 
"fulness," "hardness," and "tumor," are employed in the narratives 
which we read of such cases ; and it is quite clear, although the words 
themselves are sufficiently explicit and significant, that much confusion 



XLVI.] DIAGNOSIS. 733 

arises from this source, especially, perhaps, in confounding tumor with 
mere hardness. The same remark applies to any investigation which 
may be made from the vagina ; and it is, in every case, of the highest 
importance that we should determine if any connection exists between 
an enlargement observable from above and one which is made out 
from below. In the case of a solid tumor, free from serious adhesions, 
this is very readily recognized by such method of investigation — the 
impulse communicated from one direction being readily transmitted to 
the other. If it be a cyst or abscess, fluctuation is thus sometimes dis- 
tinguished, without any difficulty, between the two hands, which are 
simultaneously employed in the examination. But, in the case of 
mere diffused fulness, or hardness, or a tumor which is bound down 
by adhesions, the difficulty of diagnosis is increased, to an extent which 
is only fully recognized by those who have devoted most attention to 
such matters. 

Pelvic cellulitis, peri-uterine phlegmon, or parametritis, — and accept- 
ing those expressions as synonymous, — indicates, as already stated, an 
inflammation of the subperitoneal cellular tissue, possibly radiating 
thence, and always involving a tendency to the formation of abscess. 
Until within a comparatively recent period, every mysterious tumor 
or enlargement following delivery, was, without much hesitation, 
referred to this category. Recent investigation seems, however, to 
assign to it a much less important position. To no one is modern 
science more indebted, in reference to this subject, than to M. Ber- 
nutz ; but there can be little doubt that that experienced and able ob- 
server undertook to prove too much, when he thrust aside pelvic cel- 
lulitis, — merely admitting the possibility of its existence, — to make room 
for his own idea of pelvi-peritonitis. It is a dangerous thing to prove 
too much, inasmuch as anything approaching to exaggeration is apt to 
attach discredit, even to investigations which are otherwise of the high- 
est importance. But, freed from this blemish, no impartial critic can 
deny that M. Bernutz has rendered to this particular department of 
science the most eminent service, in boldly exposing the fallacies which 
attach to the familiar idea of pelvic cellulitis. 

" The slightest dissection," says the writer referred to, " shows that 
the cellular tissue subjacent to the peritoneum is so thin and scanty 
that it is impossible to separate the serous from the uterine tissue ; and 
that, consequently, it cannot be the seat of swellings, which, according 
M. Nonat's observations, attain, in the space of a few hours, to the size 
of a hen's egg. The only other possible position for the so-called 
ante- and retro-uterine phlegmons is the small band of cellular tissue 
situate at the junction of the neck with the body of the uterus, and 
this we can hardly credit, unless it be proved by an undoubted post- 
mortem examination, which has never yet been adduced. In the ab- 
sence, then, of direct proof, I may be allowed to doubt the existence of 
this affection as described by M. Nonat. I have for four years asked 
for proof of this proposition ; and, as no one has yet been able to give 
it, I shall assert that the swellings we are now considering, are certainly 
not formed by the inflammation of the thin ring of cellular tissue which 
encircles the upper portion of the neck of the uterus. In the excep- 



734 PELVI-PERITONITIS. [CHAP. 

tional cases, where this tissue is involved in the inflammation of the 
surrounding parts, it but very slightly augments the peri-uterine swell- 
ing, and this only when there exists also pelvi-peritonitis." It is not 
here denied, as will be observed, that inflammation of the subperitoneal 
cellular tissue occurs ; it is merely pointed out that anatomical research 
strongly discredits the idea that inflammation is likely to be propagated 
directly from the uterus to the cellular tissue. It would appear that 
the only situation at which the cellular tissue subjacent to the perito- 
neum has any appreciable thickness, is where it joins the broad liga- 
ments, — a situation at which all authorities admit of the probability of 
pelvic cellulitis; and even Bernutz himself confesses that phlegmons 
of the broad ligaments are justly so called ; but he points out, at the 
same time, as an inference from various elaborate dissections, by MM. 
Jarjavay and Lefort, that the disposition of the various aponeurotic 
lamellae almost necessarily directs such purulent formations as may 
ensue towards the abdominal walls, or else to the deep iliac fossa. 

Aran and Bernutz make a broad but unfortunate distinction between 
iliac abscesses and those which are now under consideration. The 
history of an ordinary iliac abscess is no doubt very different; but, if 
we are to admit that the subperitoneal tissue and the internal genital 
organs are the site of inflammation, it is surely no great stretch of the 
imagination to believe that an abscess which is the result of this may 
make its way into the iliac fossa, so that, while originating within the 
true pelvis, the bulk of the resulting tumor is actually abdominal 
rather than pelvic. 

What we owe chiefly to Bernutz, is the clear demonstration of the 
fact, that a large proportion of so-called cases of pelvic cellulitis are 
not so at all, but that the symptoms are due to circumscribed inflam- 
mation of the pelvic peritoneum. This pelvi-peritonitis is, as we have 
said, identical with the perimetritis of Matthews Duncan. " I con- 
clude," says Bernutz, " that inflammation of the pelvic serous mem- 
brane is always symptomatic, and that it is generally symptomatic of 
inflammation of the ovaries or Fallopian tubes. Thus great interest 
attaches to the study of this affection ; and it is very important thor- 
oughly to understand the symptoms, in order to describe satisfactorily 
the uterine, and more especially the tubo-ovarian diseases which occa- 
sion it." By pelvi-peritonitis, then, we understand an affection which 
is essentially a secondary or symptomatic one, — the inflammation origi- 
nating, according to Bernutz, in the uterus, tubes, or ovaries, and ex- 
tending thence to their peritoneal investment. It is difficult to under- 
stand how the disease can spread in this manner without involving the 
intermediate cellular tissue, but the difficulty is very simply solved by 
Bernutz, by the denial that any such tissue exists over the uterus, ex- 
cept at the site already alluded to between the layers of the broad liga- 
ment. That this is the case we very much doubt, and, although it 
may be extremely thin, all analogy would lead us confidently to expect 
that a trace at least of cellular tissue must there be discoverable. That 
the peritoneal affection in these cases is secondary to inflammation of 
the subjacent organs is a fact which, in regard at least to the majority 
of cases, he has succeeded in establishing ; but we do not think that 



XLVI.] TUMORS. 735 

he is warranted in assuming that pelvi-peritonitis can be produced in 
no other way. In some cases, the result has been the formation of 
cysts in the peritoneum, which are circumscribed by the inflammatory 
process, and may contain a purulent or muco-purulent fluid. In 
others, the tumor — the nature of which during life it had been impos- 
sible to determine — was discovered, on post-mortem examination, to 
consist of a mass of viscera matted together by adhesions, usually in- 
volving the tube and ovary with contiguous portions of the bowels. 
The diagnosis of this latter class of tumors is particularly difficult, as 
the structure of the mass is such as to render almost useless the valu- 
able information which we obtain in other cases from fluctuation and 
percussion. Another point of importance, in reference to such cases, is 
the possibility of a mechanical obstruction to the function of that part 
of the bowel which is involved. 

In a case seen with Mr. Moore, this appeared to us to be the cause 
of the severity and alarming nature of the symptoms. The patient 
had been confined about a month previously, and being out for her 
first drive, she imprudently got out of the carriage, and sat for a short 
time on a bench in an exposed part of the park. On her return home 
she felt unwell. The following day acute pain was complained of in 
the left side above the groin, and the symptoms generally went on 
increasing in severity, while a tumor became developed in the region 
referred to. This tumor was irregular in shape and indistinct in out- 
line, but, being exquisitely tender, it was difficult to make a satisfactory 
examination of it, further than that it was manifestly connected with a 
corresponding fulness which was easily recognized from the vagina. 
It was with the greatest difficulty that the action of the bowels w r as 
maintained ; the tympanitic distension was enormous ; and for some 
days the occurrence of obstinate vomiting prevented the administration 
of any remedies, or almost of any food by the mouth. Considerable 
benefit was derived from the use of suppositories containing tar, but 
it was on several occasions found necessary to give egress to the pent-up 
flatus by the use of O'Byrne's tube. Ultimately, after a long and 
anxious illness, this lady recovered, and the tumor disappeared. 

We have here to do only with those cases of pelvi-peritonitis w 7 hich 
are associated with the puerperal state, which constitute, indeed, nearly 
a half of all cases from whatever cause arising. The disease, of course, 
originates, in almost all of this class of cases, in the uterus, and the 
affection is therefore one of metro-peritonitis ; and this portion of the 
peritoneum is the more likely to be the seat of the lesion, the sooner 
the symptoms are developed after delivery. If after a longer interval, 
the chance of its being inflammation of the appendages is proportion- 
ally greater. 

In attempting to form a diagnosis between pelvi-peritonitis and 
pelvic cellulitis, the following are among the more important points 
which it is proper to bear in mind. In the former the affection is 
usually, though not invariably, limited to the true pelvis, and may be 
distinctly recognized from the vagina; in the latter, the true phlegmon, 
originating in the cellular tissue, cannot be reached from the vagina, 
but, tending to spread towards the iliac region, can usually be made 



736 PELVI-PERITONITIS. [CHAP. 

out by hypogastric palpation at an early stage of the case. The ten- 
dency to the formation of abscess and discharge of pus is greater in 
cellulitis than in peritonitis, so that the symptoms indicating the for- 
mation of pus may come to be of some importance in doubtful cases. 
If it be correct to assume that pelvic cellulitis, when it follows labor, 
generally originates in the broad ligaments, we can have no difficulty 
in understanding how tumors, originating in pelvi-peritonitis, and thus 
being intimately connected with the uterus, are not only more within' 
the reach of the finger, but are frequently found to produce very marked 
displacement of the uterus in proportion to the size of the swelling. 
In the more chronic variety, the diagnosis of pelvi-peritonitis may 
involve doubts as to the nature of the tumor which is recognized from 
the vagina. The difficulty is supposed to be greatest in the case of the 
affection which lias been termed " engorgement of the uterus," in which 
the tissue proper of the uterus is increased in volume; but the regu- 
larity in these cases, in the outline of the tumor, its mobility, its firm 
consistency, and the transmission downwards of movements communi- 
cated to it from above, will probably serve to enable us to form a 
pretty confident opinion. Uterine displacements of various kinds and 
fibrous tumors may also be mistaken, and erroneously supposed to be 
tumors, the result of pelvi-peritonitis. 

The formation of an abscess is probably the result which, in puer- 
peral cases, we look to with the greatest apprehension. It is only of 
late that it has been fully recognized that pus may accumulate in the 
form of abscess, not only in the cellular tissue but also within the 
peritoneum. This, indeed, forms a most important practical analogy 
between pelvi-peritonitis and the familiar pelvic cellulitis of most 
writers. The majority of all pelvic abscesses, occurring at the period 
of which we speak, are probably due to the latter affection ; but some 
of our most able gynaecologists hold a contrary opinion, and believe that 
intra-peritoneal purulent collections form the majority of grave abscesses 
in this situation. Supposing it to be admitted that the idea generally 
entertained as to the origination of pelvic cellulitis within the folds of 
the broad ligament is w r ell founded, an interesting subject of investiga- 
tion is thus suggested. Nor can we wonder that numerous dissections 
have been made, and experiments by injection or inflation of the cellu- 
lar tissue performed, with the view of determining what direction an 
abscess in this particular situation is likely to take. The question is, 
however, far from solved, and we certainly find abscesses taking quite 
unexpected directions. " The most frequent extension of parametric 
abscesses," writes Matthews Duncan, " is either upwards, or into the 
iliac fossa on either side. But they may go much further. They may 
extend along the rectum to the perineum. They may extend to the 
kidneys. They may, in assuming these directions, attack only cellular 
tissue, or, in addition, may lead to destruction of muscles, as of the 
psoas and iliacus. I have dissected such abscesses in the puerperal 
state, and in connection with non-puerperal disease, extending from 
the kidney to the uterus." 

One of the most important practical points connected with these ab- 
scesses, whether they be parametric or perimetric, is the method to be 



XL VI.] TREATMENT. 737 

employed for the detection of pus. Every clinical student is taught that 
fluctuation is the most reliable sign of the presence of fluid within a 
cavity which it fills, and is instructed how to apply the test, the manip- 
ulation being somewhat varied according as the accumulation is large 
as in ascites, or small as in an ordinary superficial abscess. In this 
strict sense, however, fluctuation is very rarely available in the diag- 
nosis of pelvic abscess, for the obvious reason that while we require, to 
produce real fluctuation and at the same time to appreciate it, two 
hands, — as a rule, in the investigation of these tumors, one hand, or it 
may be one finger only, is available. The circumstances under which 
actual fluctuation is then discoverable are to be found in those cases 
only in which the tumor has reached above the pelvic brim in the direc- 
tion of the iliac fossa or elsewhere, or when it is possible to produce the 
wave of fluctuation between the fingers and the vagina, and the other 
hand applied to the abdominal wall. The presence of fluid may, how T - 
ever, often be recognized quite easily by the finger in the vagina; but 
there are many cases in which to be certain requires a high degree of 
the tactus eruditus. " This is, however," as Dr. Duncan observes, 
" not feeling fluctuation. It is merely the educated finger picking up 
such sensations as enable the mind to perceive a collection of fluid in 
a cyst or bag. The finger cannot both produce fluctuation and feel the 
shock of the wave." 

Treatment. — The management of pelvic cellulitis and pelvi-peritonitis 
depends, in the first place, and very obviously, upon the nature of the 
case. It will depend, moreover, upon whether the symptoms are acute 
or chronic ; whether the disease is progressive or stationary • and 
whether there is already evidence of the formation of an abscess. It is 
quite clear, therefore, that on many points, the ordinary principles of 
surgical treatment must be our guide; but, in so far as the treatment to 
be pursued is identical with what a moderate acquaintance with clinical 
surgery would indicate, we shall not follow the subject. There are, 
however, many special practical considerations, most of which experi- 
ence alone can teach ; but to one or two of these we may here briefly 
advert. Of the symptoms which call for prompt treatment, none is of 
more importance than local pain. If the seat of the pain reaches above 
the brim, nothing is more grateful to the feelings of the patient than 
the application to that region of poultices and fomentations, which may 
be sprinkled with laudanum, or otherwise modified to suit the exigen- 
cies of the case. When the tumor is more truly pelvic, and can only 
be felt from the vagina, the vaginal douche sometimes gives temporary 
relief, and in other instances medicated pessaries, such as were recom- 
mended by Sir James Simpson, may be employed. Bernutz strongly 
advocated the internal use of conium, and it may even be necessary to 
use some of the preparations of opium. 

The sufferings of the patient are sometimes greatly aggravated by the 
pressure which the tumor exercises on neighboring viscera, especially 
the bladder and the rectum, when the functions of these parts may be 
seriously interfered with. The exact nature of this class of symptoms 
will entirely depend upon the anatomical relations which the tumor 
bears to contiguous parts. When the pressure is forwards, in the direc- 

47 



733 PELVI-PERITONITIS. [CHAP. 

tion of the pubic symphysis, the suffering from pressure upon the neck 
of the bladder is sometimes excruciating, and as one result of this may 
be constant calls to micturate, which is often effected with difficulty, 
the pain which is thus produced may be intense. In some instances, 
the bladder can only be emptied by the regular use of the catheter. 
When the pressure takes the other direction, the suffering is not so 
severe, but there is almost always more or less pain in the back. In 
some cases, there is obvious mechanical interference with the function 
of the bowels, the difficulty in the act of defecation, and the flattened 
condition of the faeces, showing clearly the nature of the case. In other 
instances, there is apt to be obstruction of a more serious nature, as in 
pelvi-peritonitis involving the bowel, when the patient suffers much, 
both from obstruction and from flatulent distension. In every such case, 
the action of the bowels should be scrupulously watched, and, on the 
slightest sign of obstruction, immediate means must be taken to prevent 
the possibility of serious results, by the combined action of laxatives 
and enemata. A simple injection of soap and water, with or without 
turpentine, may, in such cases, be given every night, — a mode of prac- 
tice which will, in many instances, contribute to the comfort of the 
patient. 

The treatment, generally, of a case will divide itself into the arrest 
of inflammation, the promotion of absorption, and the discharge of pus 
when abscess has actually formed. It is with the view of fulfilling the 
first of these indications that bloodletting, in such cases, is usually 
recommended. Few persons will, probably, think of general blood- 
letting. It is, at least, difficult to conceive a case in which the circum- 
stances would warrant such a measure. It is otherwise, however, as 
regards leeching, from which, in some instances, very marked and de- 
cided benefit may be anticipated. Leeches may be applied to the 
groins, the perineum, or the uterus ; but, although blood drawn from 
any of these situations may be productive of excellent results, it is ob- 
vious that the direct abstraction of blood from the uterus, — more espe- 
cially if that organ is involved, primarily or secondarily, in the morbid 
action, — is the procedure from which we may anticipate the most 
marked effect. But, if the nature of the case be such that it is impos- 
sible to introduce the speculum, the leeches may be applied to the 
vulva, taking care that they do not bite too high ; for it has happened 
that very troublesome bleeding has been the result of the application 
of leeches to the vagina, from the difficulty of reaching and controlling 
the bleeding point. " I believe/ 7 says Bernutz, "that four leeches ap- 
plied to the cervix are as good as three times that number applied 
externally ; for, not only is it nearest to the seat of inflammation, but 
the relief to all the genital organs is greater. I do not think even 
scarification can be compared with leeches, in point of utility; the 
amount of blood drawn off is, comparatively speaking, quite insignifi- 
cant ; and there is the possibility of serious consequences resulting." 

It is never necessary to apply more than three leeches at a time to 
the os and cervix, for if the quantity of blood which is withdrawn 
should not be deemed sufficient, the flow may be encouraged by a 
warm hip-bath, by means of which the quantity may often be regulated 



XLVI.] TREATMENT. 739 

at will. As a rule, it is not advisable to aim at the abstraction of a 
large quantity of blood, as a very moderate discharge is all that is 
necessary thoroughly to deplete an organ of the size of the womb; but, 
besides this, there is danger of interfering with the menstrual function, 
should we push depletion too far, — more especially if the period be 
at hand. In the actual application of the leeches, some nicety of ma- 
nipulation is sometimes required, to prevent them from crawling round 
the edge of the speculum, when they will probably fix upon the vagina, 
or even pass out by the vulva ; and, as it has happened that disagreea- 
ble symptoms have resulted from the leech making its way into the 
uterus, it is recommended, in pluripara?, or in any case where the aper- 
ture is large, to put a small plug of wool in the gaping os. It is to 
the acute stage, mainly, of the cases of pelvi-peritonitis, in which the 
uterus or its appendages are assumed to be the original seat of the dis- 
order, that leeching is applicable ; but there are, undoubtedly, cases of 
cellulitis in which congestion of the womb exists as a complication, 
where the treatment is precisely similar. And, at any stage of the 
more chronic forms, an exacerbation of the symptoms may present such 
features as clearly to call for local depletion. In the present state of 
our knowledge, it will not do to pause in these cases until our diag- 
nosis is complete. The indications which point to bloodletting as the 
proper remedy at the time being clear, it is a very secondary matter to 
determine whether the peritoneum or the cellular tissue is the part 
involved. 

Poultices, fomentations, hip-baths, and the vaginal douche, are ex- 
tremely valuable agents in these as in other affections, in controlling 
inflammatory action, and, as has already been observed, in alleviating 
pain. But the fact is, that there is no stage of the disease at which 
this class of remedies may not be found beneficial. They should be 
employed continuously in the acute stage ; and in the case of an abscess 
which threatens to point externally, the application of poultices may also 
be diligently carried out. In cases where the result of the inflamma- 
tory action has been the formation of a tumor, or more diffused hard- 
ness, it comes to be a question whether nothing can be done with the 
view of promoting absorption. At one time, when the professional 
belief in mercury was unbounded, the drug would naturally have sug- 
gested itself as an essential part of the treatment, either in the acute 
stage, in that of which we are now speaking, or in both. It must be 
confessed, however, that comparatively little faith is now placed in 
mercury as a remedial agent. Many reject it absolutely, in this and 
other diseases ; but in so passing from the abuse to the absolute neglect 
of the drug, we think that the modern physician, as in the case of gen- 
eral bloodletting, has gone too far. We should certainly recommend 
that the patient may have the chance which such a remedy affords her ; 
but, if there be anything to contraindicate the use of mercury, it may 
be abandoned with less regret than if we had more faith in its action. 
The most suitable preparation is the perchloride, which may be admin- 
istered in doses of ygth of a grain, and should never be carried beyond 
the stage at which the gums, etc., indicate, faintly, commencing 
mercurialization. 



740 PELVI-PERITONITIS. [CHAP. 

Iodine is another remedy of the same class, which many will employ 
w T ith less hesitation, either in the form of iodide of potassium internally, 
or, it may be, by the external application of the tincture or ointment. 
The latter may be applied when the tumor is hard and chronic, and 
can easily be recognized through the abdominal walls ; or they may be 
employed in similar circumstances through the vagina, a method of 
treatment which has been found beneficial in many of the uterine dis- 
orders familiar to the gynaecologist. Blistering has been strongly advo- 
cated by some after the acute stage is past, and no one will deny that 
experience would encourage us to look to this mode of treatment for 
satisfactory results; but we confess to a preference for the external 
application of iodine, by which irritation may be maintained for a long 
period, its action being, of course, kept within moderate bounds so as 
not to irritate too much. 

In cases in which pelvic abscess has formed, and the ordinary signs 
reveal that pus is present in considerable quantity, it comes to be an 
important practical point whether we are to operate by incision or leave 
the case absolutely to nature. In so far as can be gathered from the 
experience of modern practice, abscesses, wherever existing, are now 
much less frequently opened than was the ordinary practice of a quarter 
of a century ago. But, whatever be the case as regards ordinary surgi- 
cal practice, it is certain that, in the management of pelvic abscesses, 
particular care and discrimination is necessary. Caution is more im- 
peratively demanded when the tumors show a tendency to point in the 
groin or elsewhere above the pelvis; but it must at the same time be 
remembered that, while the danger of premature operation is admitted, 
the greater danger of rupture of the sac and escape of its contents into 
the peritoneal cavity must not be overlooked. Some have said that 
such an abscess should be opened when it threatens to burst into the peri- 
toneum ; but in what this threatening consists, or how we are to rec- 
ognize the danger, is what no one has attempted to show. If the 
abscess is acute in its history and progress, it is better to leave the 
operation to nature ; but, if it is mature and chronic, and shows no 
tendency to point externally, it comes to be a very delicate matter to 
determine whether we shall operate or not. If we dread its opening 
into the peritoneum, we must at the same time bear in mind what the 
experience of West, Bernutz, Aran, and others has clearly shown, — 
that, even if we open an abscess, this does not prevent its subsequent 
perforation into the peritoneal cavity. If the symptoms of hectic fever 
manifest themselves, or if the tumor gives rise to great suffering, the 
idea of operation will naturally receive encouragement; but, in the 
absence of these conditions, it is always better to wait. Pelvic abscesses 
may point at various situations externally, which are well known to 
the surgeon, or they may only be reached through the vagina, or even 
by the rectum; but, in any case, when the operation is resolved upon, 
the opening should be free, so as to admit of a thorough evacuation of 
the cyst. " Old pelvic abscesses," Dr. Duncan observes, "demand 
even boldness in operating. ... I have repeatedly operated in cases 
where I knew the abscesses were several years old ; and in such cases 



XLVI.] TREATMENT. 741 

sometimes more than once ; and I have never had reason to doubt the 
propriety of the treatment/' 

There is another class of pelvic tumors, the nature of which was 
recognized by Ruysch in 1691, but which has received very little atten- 
tion except at the hands of quite modern gynaecologists. These are the 
sanguineous tumors — the result not unfrequently of menstrual accumu- 
lation outside of the uterus — to which the name of Peri-uterine Hema- 
tocele has been given. This question is too complicated to enter upon 
here, and, indeed, there is only one section of it — the intra-pelvic hemor- 
rhage occurring in extra-uterine pregnancies — which comes strictly 
within the scope of our subject. These tumors are merely mentioned 
at this place, as they might possibly give rise to difficulties in the diag- 
nosis of the affection which we have just been considering. 

Sudden death in the puerperal state is a subject which of late has 
attracted considerable attention, more particularly since the phenomena 
of thrombus and embolism have been more thoroughly understood, as 
these are undoubtedly the cause of death in a large number of the fatal 
cases. 

In the course of puerperal fever, as has already been stated, what we 
may call septic embolism is by no means of un frequent occurrence. 
Among other localities, the detached clot may lodge in the pulmonary 
artery and its branches. If a small branch only is occluded, the symp- 
toms are correspondingly slight, but if the main trunk, or a large branch 
is blocked, death may either be immediate, or may occur after an in- 
terval, during which the leading symptoms are precordial oppression, 
dyspncea, cyanosis, and a low temperature. But it is not only in the 
course of a case of septicaemia that this may happen. The highly 
fibrinated condition of the blood, natural to the normal condition of 
the woman at this period, may be still further increased as the result 
of exhausting haemorrhage, a condition manifestly favorable to the for- 
mation of thrombus, and the subsequent accident of embolism. But 
even in a case in which no single symptom has occurred to disturb the 
approach of convalescence, embolism may occur quite unexpectedly. 
If not immediately fatal, there is good reason to believe that, under the 
favorable circumstances of absorption, disintegration of the clot, or 
the establishment of collateral circulation, recovery is by no means 
impossible. 

Cerebral embolism is also an occasional cause of sudden death in the 
puerperal woman. Several interesting cases of this are recorded in Dr. 
Fordyce Barker's recent work, from which it would appear that the 
left middle cerebral artery is the most frequent site of the lesion, so 
that, as Dr. Barker observes, we might expect aphasia to be a leading 
symptom. The difficulty in such a case would be to distinguish between 
apoplexy and embolism. 

The entrance of air into the veins is well known as a cause of sudden 
death. There is no doubt that the provisions of nature after delivery 
are not such as to favor the ingress of air to the uterine veins ; but it 
has been demonstrated that under a certain degree of pressure it is pos- 
sible, and it is believed by some to be a rare cause of sudden collapse. 



742 PELVI-PERITONITIS. [CHAP. 

Twenty years ago, no one could presume to write a treatise on Mid- 
wifery without an elaborate disquisition on the subject of Anaesthesia. 
The then recent discovery of chloroform and of the anaesthetic power 
of sulphuric ether was an era in the history of surgery ; and we cannot 
wonder that the obstetrician should have claimed for his art the immu- 
nity from pain and the other advantages of which his surgical brethren 
were so gratefully availing themselves. We look back to this period 
(circa 1848), and turn over the pages of the pamphlets which mark the 
bitterness of the controversy which was then being waged, with a feel- 
ing partly of amusement and partly of humiliation. The theological 
tone which was prevalent in some quarters is the most extraordinary 
feature in the whole affair ; but how sensible and able men could write 
such trash, and argue gravely against the iniquity which was being 
perpetrated in relieving women from the effects of the Divine curse 
"in do! ore paries" will ever remain an inscrutable psychological phe- 
nomenon. 

There are many agents which have been classed as anaesthetics, and 
there no doubt are many more. At present, ether and chloroform are 
the only two which are habitually employed ; and to these we may 
perhaps add chloral, as it is now pretty well known that a patient, 
thoroughly under the influence of this drug, may go through the whole 
stages of labor without any sensation of pain or any consciousness of 
the process which is going on. Ether and chloroform, however, the 
one in America and the other in this country, are, from the evanescent 
nature of their effects, preferred to those agents whose operation is 
more permanent, and after which disagreeable results are more likely 
to accrue. At first, partly from the impulse and surpassing interest 
given to the subject by its eminent discoverer, chloroform was used 
somewhat indiscriminately in cases of labor which were in all respects 
normal ; but subsequent experience has shown that such wholesale use 
of anaesthetic agents cannot be supported, either by argument or by 
practical experience. 

The result of numerous experiments has proved that chloroform, 
which is sparingly soluble in the blood, travels through the circulation 
in considerable quantity, in an uncombined state. It having a strong 
affinity for oxygen, the ordinary chemical changes which normally 
take place in the blood, are thereby materially interfered with, and Dr. 
Snow has shown that, in consequence of this, the quantity of carbonic 
acid evolved from the lungs is materially diminished. Such an effect, 
if of short duration, will probably produce no very serious result upon 
the economy; but should the action be unduly protracted — which is 
necessary, if we wish absolutely to annihilate pain in labor — we can 
well imagine that the ultimate results may be in some way or other 
unsatisfactory. It has frequently been observed and many have noted 
it as a remarkable fact, that the effect of chloroform does not seem in 
any way to arrest or even to modify the expulsive efforts ; but, if we 
bear in mind what has been said in regard to the reflex action produced 
by an excess of carbonic acid in the blood, the experiments of Dr. Snow 
afford a ready explanation of this, which was at one time supposed to 
be a phenomenon, unique in itself, and of great interest. 



XLVI.] ANESTHESIA. 743 

The effect of chloroform on the nervous system is, however, the point 
in regard to which, in the practice of midwifery, the greatest amount 
of interest attaches. In the view which we take of the subject, by far 
the most important point is that a moderate dose of chloroform may 
annul, or at least deaden sensation, without disturbing the power of 
motion or consciousness. This enables us to alleviate the sufferings of 
our patient by a trifling dose, and without bringing her fully under 
the influence of this powerful agent. The interference, therefore, with 
the chemical changes which are constantly going on in the blood is 
proportionally diminished. The further we push the administration 
of chloroform, or of the other anaesthetics, the more thoroughly is the 
cerebro-spinal or reflex function influenced, until at last the motor fibres 
of the respiratory nerves are affected, and stertor indicates that the 
Ultima Thule of safety has been reached. 

The disadvantages of chloroform in the practice of obstetrics are, in 
the first place, the tendency to vomiting, which is so apt to be produced 
in the course of its administration. For obvious reasons, however, the 
stomach rarely contains much food at the period of delivery, and this 
is no doubt the reason why vomiting is, in midwifery practice, com- 
paratively rare. Still, it does occur; and more than that, it occasion- 
ally persists for a considerable time, to the manifest disturbance of the 
patient during the post-partum period. Partly on this account, and 
partly, it may be, in consequence of the effect which is produced on the 
nervous centres, it has been pretty clearly established that the indis- 
criminate use of chloroform, or other anaesthetics, predisposes to haemor- 
rhage after delivery. Another objection which has been stated is 
perhaps of less importance, — that in operations, the annihilation of 
sensation removes what was before a reliable safeguard, as, for example, 
when the blades of the forceps are applied, the patient is no longer 
conscious of the pain caused by including a portion of the vaginal 
mucous membrane in the lock — the suffering produced by which would 
previously have caused her to cry out. 

The question of anaesthetics seems to us to stand thus. In eclampsia, 
in some cases of mania, and in all cases of operative midwifery, it is, 
without exaggeration, invaluable. In ordinary cases, it is always to be 
used with caution ; but if employed in small quantities on a handker- 
chief on the approach of each pain, towards the termination of the 
second stage, it can never do harm. It thus allays pain and assuages 
nervous irritability ; and, in the hand of the skilful practitioner, it is a 
power for good and never for evil. 



APPENDIX. 



THE BIPARIETAL OBLIQUITY OF NAEGELE. 

Foe reasons which have already been stated, but chiefly with the 
view of avoiding controversial matters in the text, I have thought it 
better to express; in the form of an appendix, the reasons which have 
led me to reject the theory of biparietal obliquity as an element in the 
mechanism of parturition. The 1 following observations, with some 
modifications, are mainly taken from my work on the Mechanism of 
Parturition, published in 1864. Tin 1 error of Naegele is certainly not 
so commonly taught as it was once, and many distinguished teachers and 
writers have completely abandoned it; but the fact of its still being a 
matter of common belief, together with the respect which is due 4 to any 
doctrine having the stamp of authority of the distinguished Professor 
of Heidelberg, makes it both necessary and fitting to analyze the sub- 
ject with some care. But, as some doubt has occasionally arisen in re- 
gard to the exact nature of NaegelcV views, it will be proper first to 
make sure what his opinions were, before proceeding to refute them. 

In his celebrated essay, originally published in Meckel's Archiv, 
'Naegele describes, in addition to the pelvic and occipito-frontal ob- 
liquities, a third obliquity, the biparietal. He maintained, that, in re- 
gard to its transverse measurement, the head entered the brim obliquely, 
"so that the greatest breadth of the skull (from one tuber par let ale to 
the other), as also the breadth of its base, never in its passage, under 
ordinary circumstances, coincides with the diameter of the brim." On 
this point he says also, in describing the first position : 

" The head has not at the brim a direct but a perfectly oblique position, so that 
the point which lies lowest or deepest is neither the vertex nor the sagittal suture, 
but the right parietal bone. The sagittal suture is nearer to the promontory of the 
sacrum than to the pubis, and divides the OS uteri, which is directed backwards 

and generally somewhat to the left, into two very unequal parts The higher 

the head is, the more does its long diameter approach the transverse of the brim, 
and the more oblique is its position, on account or which the right ear can generally 
be felt without difficulty behind the pubis, which would not bo the case if the 
head had a perpendicular direction." 

These extracts leave no room for doubt that his meaning was really 
a lateral flexion of the head, an approximation of the ear to the corre- 
sponding shoulder. He also describes, but in terms which, being some- 
what vague, have led to some misapprehension, that there is a bi- 
parietal obliquity at the outlet; but in this he is, as has been observed 
in the chapter on the " Mechanism of Parturition/' quite correct. The 



746 



APPENDIX. 



following observations, it is proper here to explain, have reference to 
the first cranial position. 

Biparietal Obliquity. — It will be understood that, in considering the 
second kind of obliquity — that, to wit, by means of which the head 
being rotated on its occipito- frontal axis brings the left ear, in the po- 
sition which we are considering, towards the left shoulder — I must, in 
pursuance of my plan, view the head in reference to the axis of the 
brim alone. The presenting point of the cranium I shall consider 
throughout, until the head reaches the floor of the cavity, as that 
through which the axis of the brim passes, its situation being altered 
only by a variation in the different kinds of obliquity. 

Most modern writers, including the many eminent obstetricians of 
our time, agree in adopting Naegele's view with reference to this ob- 
liquity. It is, therefore, with much diffidence and hesitation that I here 
submit a contrary opinion, although I have only convinced myself of its 
truth after a careful and laborious study of the progress of labor. I am 
persuaded that, in a pelvis of ordinary dimensions, the usual course of 
labor is for the head to enter directly in the axis of the brim, with the 
sagittal suture equidistant from pubis and sacrum. The accompanying 
illustrations show this more plainly, and in both the observer will re- 
member that he is looking upwards and forwards, the axis of vision 



Fig. 197. 



Fig. 198. 





In Figs. 197 and 198, the floor of the pelvis has heen removed by a section, including the greater 
part of the walls of the cavity. In Fig. 197, the head is represented as descending directly in the axis 
of the brim. The dotted circle shows the effect on the apparent position of the os uteri of a slight 
displacement to the side. In Fig. 198, the head is represented as descending in the position described 
by Naegele. 



corresponding to that of the brim. The direct position, as here shown, 
is in most respects the same as that which was taught by the leading 
obstetricians who immediately preceded Naegele. He, however, dis- 



APPENDIX. 



747 



covered and first announced the incontrovertible fact which is set forth 
in the following words : 

"The finger which is introduced in the central or middle line of the pelvic cavity, 
and brought in contact with the head, will touch the right parietal bone in the 
vicinity of the tuber At the brim, the head does not assume a perpendicu- 
lar, but perfectly oblique position (kerne gerade, sondern eine ganz schiefe Stellung), 
so that the part which is situated lowest or deepest is neither the vertex nor the 
sagittal suture, but the right parietal bone." 

I repeat that the fact thus stated in general terms is incontestable, 
inasmuch as it obviously refers to the axis of the cavity ; but Naegele 
goes beyond this, and pushes his conclusions much further than the 
facts of the case warrant, when he says that the sagittal suture is nearer 
the promontory of the sacrum than the symphysis pubis, and that the 
biparietal measurement can never during labor coincide with the plane 
of the pelvic entrance. I may mention here that, although I began 
my study of the subject with a firm conviction that Naegele was right 
in this particular, I have been step by step driven to the conclusion 

Fig. 199. 




Fig. 199 shows the great amount of lateral obliquity (qua the horizon) of the head advancing in the 
axis of the brim, the centre of the sagittal suture being, although much nearer the sacrum, exactly 
midway between the promontory of that bone and the symphysis pubis. It shows also how during 
the whole of this stage of labor, the right tuber parietale may be described, in general terms, as the 
part which first meets the finger, or as lowest in the pelvis, advancing as it does in the direction of 
the dotted line parallel to the axis of the brim. If the head were in the transverse position, the sink- 
ing of the tuber parietale would be still more decided, but in that case it would be slightly to the left 
of the middle line. 

a B, the plane of the brim meeting the horizon at an angle of 60° at a. 

c r>, the axis of the brim passing through the centre of the sagittal suture and the coccyx, and 
meeting the horizon at r> at an angle of 30°. 



that he is perfectly wrong. It is perhaps unnecessary to say that the 
view which I take of the position of the head at the brim is, albeit 
somewhat heterodox, far from original. Nor is the doctrine without 
powerful supporters, as this is the view entertained and clearly ex- 
pressed by Velpeau and Cazeaux in France, and more recently in this 



748 APPENDIX. 

country by Dr. Matthews Duncan ; and several other observers, among 
whom I may mention Drs. West and Paterson, 1 have arrived indepen- 
dently at the same conclusion, which they have expressed in a more 
cursory but not less decided manner. M. Cazeaux expresses it as 
follows : 

" Avant la rupture de la poche des eaux, la tete du foetus est legerement flechie 
sur le devant de la poitrine, et les rapports des diametres de la tete avec les diame- 
tres du detroit superieur sont les suivants ; le diametre occipitofrontal est parallele 
au diametre oblique gauche du detroit superieur ; le diametre biparietal est parallele 
au diametre oblique droit; la circonference occipito-frontal de la tete est parallele 
au pourtourdu detroit superieur; Paxe de ce detroit superieur passe par le diametre 
trachelo-bregmatique." 

The arguments of Naegele on this point are stated, as indeed all his 
views are, with great clearness and precision, and are, I admit, appar- 
ently conclusive and convincing. But I do not despair of being able 
to show that he has been led into error, if my readers will only deign 
to put aside for a time a preconceived opinion, and study the subject in 
nature. I may fail in any argumentative attempt to show that Naegele 
was wrong, or I may be met with reasoning more subtle than my own ; 
but I would only ask that, as my arguments are founded upon practi- 
cal research, those who would refute them should test the matter fairly; 
a task which will involve some labor, but which is within the power 
of every practitioner in midwifery. 

In admitting the general accuracy of most of Naegele's descriptions, 
I assume that the fundamental error from which, more than any other, 
his mistake arose, was ignorance, at the time he wrote his essay, on the 
subject of the great obliquity of the brim in respect to the horizon. 
There must, I think, have been remaining in his mind some remnant 
of the old idea of the horizontal brim ; for it must be remembered that 
his attention was not directed to the subject of the relation which the 
pelvis bears to the trunk and limbs, until some years after the date of 
the publication of his paper on the mechanism of parturition. If the 
brim were indeed parallel to the horizon, or nearly so, the fact of the 
finger meeting the parietal bone in the vicinity of its tuber would be 
clear and irrefragable evidence of the so-called lateral or biparietal 
obliquity of the head. But if we do not allow ourselves to lose sight of 
the fact that the brim is inclined at an angle of 60°, and that the vertex 
or presenting part passes downwards and backwards so obliquely as to 
meet the horizon at an angle of 30° — even admitting that the right 
parietal bone in the vicinity of its tuber is the lowest part in the pelvis 
— I cannot see how this is to be accepted as evidence of anything else 
than that the head is advancing directly in the axis of the brim, but 
very obliquely with regard to the cavity, and still more so with refer- 
ence to the horizon, as is shown in Fig. 197. 

If to this great and admitted obliquity we superadd that which, 
according to Naegele, separates the sagittal suture from the axis of the 
brim, so as to bring the middle part of the suture opposite the fourth 
division of the sacrum; "whether," says the younger Naegele, "the 

1 Glasgow Medical Journal, October, 1862. 



APPENDIX. 749 

head stands deeper or shallower," we must first believe that the trachelo- 
bregmatic measurement is as nearly as possible parallel to the horizon. 

The first difficulty which shook my conviction in the accuracy of 
Naegele's statement was here encountered. Granting for the moment 
that his description is correct, let any one take a foetal skull and place 
it in the dried pelvis in such a position that the vertex is approaching 
its floor, with the sagittal suture directed as above described, when he 
will find — and there is, I think, no avoiding this conclusion — that the 
ear could in all circumstances be felt with the greatest ease ; and yet we 
all know that it is almost always a matter of considerable difficulty to 
reach the ear at this stage, even more so indeed than when the head is 
situated higher. This difficulty has not by any means been overlooked 
by Naegele ; but having adopted one fundamental error, he makes this 
the standard by which he gauges deviations from his theory, and thus 
is inevitably led further astray. He explains it thus : " The higher 
the head is, the more oblique is its direction, for which reason the ear 
can generally be felt behind the pubis without difficulty, which would 
not be the case if the head had a straight direction." 

I admit that on the first blush this argument has a significance, 
which it does not, however, maintain on closer examination. In the 
first place, he commits himself to the opinion that this alleged obliquity 
has no reference to the resistance which the head experiences from the 
pelvis, inasmuch as it is greater before this resistance can have come 
into play. He then goes on to assume that the fact of the ear being 
left behind the pubis at an early stage of labor, is a proof of this 
obliquity. With reference to this point, I would remark that he -seems 
to me, throughout his whole essay, to put too much weight on the 
facility with which the ear may be felt at the beginning of labor. That 
it may in many cases be so felt is an undoubted fact ; but as far as my 
experience goes, I have in the great majority of cases found it no such 
easy matter to reach the ear, in any stage of labor, as Naegele would 
have us believe. When I can so reach it, it only proves to me, what 
Naegele himself admits, that the head approaches the transverse diameter 
more than usual. For it must be remembered that the upper part of 
the pubic symphysis is within easy reach of the outlet, and that, on 
account of the inclination of the brim, when the ear moves to the side 
it moves at the same time upwards along the ilio-pectineal line, and 
consequently further from the finger. This then is a mere assertion of 
Naegele's; his proofs are in no degree incompatible with the idea of a 
direct entrance of the head. I am quite willing to admit that in some 
extreme cases in which the ear is felt with Unusual ease, as well as on 
other rare occasions, there may be some exceptional obliquity ; but I 
am perfectly convinced that this is the exception, and the direct entrance 
the general rule. But there are other arguments familiau to every 
obstetrician which must be met, and, if possible, refuted. 

" The sagittal suture," says Naegele, " divides the os uteri, which 
projects backwards and generally somewhat to the left, across into two 
very unequal segments." Mark how ingeniously he argues from a 
preconceived opinion, and trims his facts to suit his theory. We may 
allow the alleged inequality of the segments in the meantime to pass ; 



750 APPENDIX. 

but as this is quite insufficient to account for the amount of obliquity 
which he describes, he maintains that the os is displaced in the very 
directions which suit his argument — viz., backwards and to the left. 
For it will be observed, on a reference to Fig. 197, that the eifect of a 
slight displacement to the left is, in the direct position at the brim, to 
throw the small segment forwards, and it will be understood at a glance 
that the further effect of a displacement backwards would be to leave 
the sagittal suture concealed by the anterior lip of the os; whereas, by 
bending the head towards the left shoulder, his theory restores the rel- 
ative positions of os and suture. This is the flimsiest of all his argu- 
ments, inasmuch as it is purely theoretical, and depends entirely for its 
accuracy on the correctness of his original statement in regard to the 
obliquity. The difficulties in determining the relations of the os during 
labor are very great; but taking, as I do, the fact of the sagittal suture 
crossing the os at the beginning of labor as evidence of the direct entrance 
of the head, I see no reason to doubt that the centre of the os corre- 
sponds pretty nearly to the axis of the brim. I even doubt the general 
accuracy of the assertion that the smaller segment is behind, and I have 
certainly, at an early stage of labor, found it to vary considerably in 
this respect. Dr. Paterson, who, although admitting this fact, is never- 
theless convinced that the head enters the brim directly, attempts to 
account for it by supposing that the os is displaced forwards ; but I 
rather think that he has no more proof to offer of this statement than 
JNaegele had of his, or than I might have if I chose to assert that the 
os was always displaced to the right merely because this would suit my 
purpose. 

The statement which accompanies the above, to the effect that the 
sagittal suture is much nearer to the promontory of the sacrum than to 
the pubis, is equally erroneous. But, with reference to this, a certain 
misapprehension is apt to occur, if we use, instead of the words of 
Naegele, the expression, " nearer the sacrum," which some modern 
writers employ. For, as a natural consequence of the head advancing 
m the axis of the brim, the suture is beyond all doubt near the sacrum; 
but it is as certainly no nearer to the promontory oftlie sacrum. I think 
there is no one who has a correct idea of the relation which the pelvis 
bears to the vertebral column, and who will introduce his whole hand 
with a view to determine the position of the head at the brim, who can 
fail to arrive at the same conclusion as that which I have attained. 
For my part, I have left no means untried by which this might be 
tested. On introducing an instrument which is well known to surgeons 
as Professor Buchanan's rectangular staff for lithotomy, I have been 
able to place the angle on the second bone of the coccyx, inclining the 
short limb until it coincided, as nearly as I could guess, with the axis 
of the bnim, when it never failed to guide me, if properly placed, to 
the sagittal suture, or some point very near it, on either side. I have 
even attempted a crucial experiment by measuring, by means of a 
flexible scale, the distance from the sagittal suture to the promontory 
of the sacrum on the one hand, and the pubis on the other; and 
although, for obvious reasons, the results were not so accurate as to 



APPENDIX. 751 

warrant of themselves any definite conclusion, they certainly tended to 
confirm my belief. 

But the greatest difficulty of all, and the fact which, more than 
anything else, seems to confirm Naegele's theory, is the situation in 
which the tumor called the caput succedaneum forms, in those cases in 
which the waters have escaped, and the head is exposed at an early 
period of labor to the pressure of a rigid and undilatable os. On this 
point I have to acknowledge my obligation to Dr. Matthews Duncan, 
whose researches on the evidence afforded by the situation of the swell- 
ing, as described by Naegele, solved my only remaining doubt on the 
subject. Every accoucheur has had frequent opportunities of confirm- 
ing the accuracy of the following statement of Naegele's, and w r hich 
apparently affords striking corroborative proof of the accuracy of his 
assertions : 

" In certain circumstances, a swelling of the cranial integuments forms after the 
os has begun to dilate, which in the further progress of labor, when the os changes 
its situation and direction, and the head its position against it, disappears again by 
degrees; nevertheless, as dilatation proceeds, it may still be felt for some time, 
although much softer. This swelling (in that position of the head which we are 
talking of) is situated upon the right parietal bone, close to its upper edge, and 
equidistant from both angles. Sometimes a small piece extends over the suture to 
the left parietal bone ; its circumference depends upon the degree of dilatation which 
the os uteri has attained." 

Now this situation of the swelling may indicate one of three things : 
the os may either be inclined forwards; or it may be subjected to greater 
pressure at certain points of its circumference; or, again, the head may 
be placed obliquely. Of these, with the proof which I elsewhere have 
of the direct entrance of the head, I consider the last as the most im- 
probable of the three. It must always be remembered that, to account 
for the degree of obliquity described by Naegele, we must adopt in 
addition his theory that the os is displaced backwards and to the left ; 
but nevertheless we must endeavor to account for the fact that the bulk 
of the swelling at least is to be found at the right parietal bone. I 
have already alluded to the theory advanced by Dr. Paterson, that the 
os is inclined forwards, which would, if correct, afford a most satisfac- 
tory explanation of the phenomena as detailed above. Proof of its 
accuracy is, however, wanting ; and indeed the difficulties which an 
examination offers are such that we cannot hope for a strict demonstra- 
tion of the fact, even if true, unless we were to argue from the assumed 
fact that the entrance of the head was direct, and thus adopt the very 
error in reasoning which has led Naegele astray. 

The theory by which Dr. Matthews Duncan attempts to account for 
this, demands a separate consideration. This able writer is of opinion, 
that it is a mistake to suppose that the thickest or most prominent part 
of the swelling corresponds to the centre of the area upon which it has 
been formed, but that this is to be found in the direction in which the 
least resistance is offered to its formation. Applying this argument to 
the formation of the swelling in this stage, he says : 

" The caput succedaneum of the first stage of labor is often formed after the head 
has passed the brim of the pelvis, and is lodged in the upper half of the cavity of 
the bony pelvis. Were we to be cautious and exact in reasoning, all such swellings 



752 APPENDIX. 

should be excluded from the argument, for evident reasons. It is only those formed 
at the plane of the brim, or very near it, that can, under any circumstances, afford 
assistance in settling this question : under the actual deficiencies of exact data, we . 
must be content with stating principles. Now it is evident that the direction of the 
caput succedaneum of the first stage will be that of least resistance — that is, the 
direction of the axis of the undilated vagina; in other words, the caput will be 
thickest when the head is least supported, and may, in other parts with the centre 
of the os uteri, be so inconsiderable as not to attract notice. Further, and for the 
same reason, the centre of the caput succedaneum, or the centre of the os uteri, will 
not correspond with the thickest portion of the swelling, but in this case be behind 
it, or near the left parietal bone. The oblique direction downwards and forwards 
of the vagina will lead the caput in that direction, and the support given by the 
posterior wall of the vagina to the posterior half of the space inclosed in the circle 
of the os uteri will cause thickness of the swelling over the right, and comparative 
thinness over the left parietal bone, and displacement of the thickest portion of it 
forward in the pelvis, that is, in the direction of the right parietal and away from 
the left parietal bone." 

This theory is extremely ingenious and affords to me the only ex- 
planation of the facts described by Naegele, which gives a rational and 
satisfactory solution of the problem, in conformity with the phenomena 
which I myself have observed. For its absolute accuracy I cannot 
vouch ; but I cannot help thinking that it is in the main correct, or at 
least that it points out the direction in which we are to search for truth. 

My last argument is one which, while of itself it goes for nothing, is 
at least admissible as corroborative proof, and is drawn from a consid- 
eration of the cm bono f No such argument would for a moment stand 
against a single observed fact, and we have too many instances of this 
in the history of the subject to permit us to tread otherwise than warily 
on such dangerous ground. But after all we may surely ask what is 
the use of this alleged obliquity ? It is not only said to take place 
before the head is actually engaged in the brim, but, according to 
Naegele, is more marked then, and cannot therefore be due to any 
resistance from the hard parts of the pelvis. But, even if it did not 
occur till the head experienced the resistance of the brim itself, it is 
difficult to conceive what mechanical advantage would result therefrom, 
as there is ample room and to spare in any well-formed pelvis for the 
biparietal measurement of a full-sized foetal cranium. In the case of the 
long diameter of the head, we are able, without any difficulty, to assign 
a cause for the obliquity which causes the occiput to pass in advance of 
the forehead, but in this case I cannot imagine a single theory which 
will bear examination for a moment. I can understand how it may 
exceptionally occur, being rendered necessary by a deformed pelvis, a 
distended rectum, or some other cause; but I am perfectly convinced 
that the rule in the vast majority of cases is, that the head enters the 
pelvis directly , in — or nearly in — the axis of the pelvic brim. 



INDEX. 



Abdomen, appearance of, in pregnancy, 156 

flattening of, in pregnancy, 156 
Abdominal pain, in pregnancy, 243 

pregnancy. 196 

tumors, diagnosis of, from pregnancy, 157 
Abortion, causes of, 369 

comparative frequency of, 368, 385 

definition of term, 367 

different periods of, 368 

distinction between threatened and inev- 
itable, 376 

distinguished from delayed menstruation, 
374 

expulsion of placenta in, 377 

management of haemorrhage in, 382 

management of placenta in, 383 

retention of the ovum in, 377 

retention of placenta in, 376 

symptoms of, at various periods, 373 

tendency to repeated, 373 

treatment of, 379 

treatment after, 385 

treatment of inevitable, 382 

treatment, preventive, in T 379« 

treatment of threatened, 379. 381 

use of placental forceps in, 384 
Accidental haemorrhage, 387, 401 

dangers of, 403 

causes of, 388, 401 

evacuation of liquor amnii in, 403 

Goodell on, 402 

induction of premature labor in, 562 

operation of turning in, 403 

site of placenta in, 401 

symptoms of, 388, 389, 401, 402 

treatment of, 403 

use of Barnes's bags in, 403 

use of styptics after delivery in. 403 
Accoucheur, armamentarium of, 270 

duties of, in labor, 270 
After-pains, 61 1 

treatment of, 611 
Agalactia, 615 

causes of, 615 

treatment of, 615 
Ala vespertilionis, 64 
Albuminuria, in pregnancy, 233 

connection of, with puerperal eclampsia, 
673, 675, 677 

connection of, with puerperal insanity, 
660. 668 

detection of, in urine, 679 

effect of, in inducing premature labor, 
682 

morbid anatomy in, connected with puer- 
peral eclampsia, 678 



on renal veins as 



Albuminuria, pressure 
cause of, 679 
symptoms of, 235 
treatment of, 236, 683 
Allantois, formation of, 105 
Amnion, dropsy of, 236, 240, 597, 599, 601 
dropsy of, as a cause of uterine inertia, 

597, 599, 600 
formation of, 104 
Anaesthesia, in midwifery, 742 
in eclampsia. 684, 743 
in mania, 670, 743 
use of chloral, 670, 684 
use of chloroform. 670. 684, 742 
use of ether, 742 
Angeioleucitis, connection of, with puerperal 

fever, 700 
Anorexia, in pregnancy, 223 
Anteflexion, of uterus in pregnancy, 245 
Anteversion, of uterus in pregnancy, 245 
Anus, examination by, in pregnancy, 165 
Aorta, compression of, in post-partum haemor- 
rhage, 412 
Appendix, 745 
Area germinativa, 103 
Areola, 154 

changes in, during pregnancy, 154 
umbilical, 156 
Arm, displacement of, in breech presenta- 
tions. 338 
dorsal displacement of, obstructing labor, 

593 
examination of, in transverse presenta- 
tions, 343, 345 
prolapse of, in transverse pres 

351 
presentations, see Transverse 
tions. 
Articulations, anchylosis of, foetal, 
ing labor, 586 
inflammation of pelvic, 243 
mobility of. during labor, 31, 36, 242 
Ascites, in foetus, obstructing labor, 586 
in pregnancy, treatment of, 234, 239 
Asphyxia, indications of, in breech presenta- 
tions, 339 
Astringents, use of, in post-partum haemor- 
rhage, 413 
Auscultation of foetal heart, 16S 
of foetal heart in twins, 170 



'Batllottement, 167 

Bandages, abdominal, application of, 283, 

411, 599, 608 
Belladonna, use of, in rigidity of os, 570 



entations, 
Presenta- 
obstruct- 



48 



754 



INDEX. 



Bimanual version, 350, 522 

conditions favorable to, 523 
method of Braxton Hicks, 523 

Binder, use of, in America, 283 

Biparietal obliquity, in cranial presentations, 
288, 292, 297, 298. See Appendix. 

Bladder, calculus in, obstructing labor, 579 
catarrh of, in pregnancy, 233 
distension of, obstructing labor. 578 
distension of, as a cause of uterine iner- 
tia, 597 
distension of foetal, obstructing labor, 586 
prolapse of, obstructing labor, 578 

Blastodermic vesicle, formation of, 103 

Blood, condition of, in pregnancy, 225 

Blunt hook, 504 

use of, in breech presentations, 337 
use of. in decapitation, 505 

Breech presentations, 324 

arms passing up alongside head in, 338 

artificial delivery of head in, 340 

birth of head in, 331 

birth of shoulders in, 330 

compression of umbilical cord in, 336, 339 

craniotomy in, 542 

critical periods in, 336, 339 

diagnosis of, 326 

dorso-anterior positions in, 326 

dorsT-posterior positions in, 326 

dragging on lower iimbs in, to be avoided, 

338 
first position in, 327 
second position in. 330 
third position in, 332 
fourth position in, 333 
hydrocephalus, with, 583 
indications of asphyxia of child in, 339 
management of, 336 
mechanism of labor in, 325, 327 
movement of restitution in, 328 
movement of rotation in, 327, 332, 333 
nature of assistance to be rendered in, 

335 
natural termination of, 328 
occipito-posterior termination of, 332 
operative interference in, 335 
special risks of, 329, 332, 335 
use of the forceps in. 337, 341, 497 
use of vectis, fillet, or blunt hook in, 337, 
503 

Brow presentations; 323 

Bulbi vestibuli, 49 



Cadaveric poison, connection of, with puer- 
peral fever, 703, 718 
Caesarian section, see Hysterotomy. 
Caput succedaneum, 264 

in cranial presentations, 264, 295 

in face presentations, 317 
Caruncula? myrtiformes, 50 
Catheter, mode of introducing female, 49 
Cephalotribe, use of the, in craniotomy, 538, 
544 

use of the, in decapitation, 509 
Childbed fever, see Puerperal Fever. 
Chloral, use of, in midwifery, 670, 684, 742 

in puerperal eclampsia, 685 

in puerperal mania, 67u 
Chloroform, use of, in midwifery, 606, 670, 
684, 742 

disadvantages of, in midwifery, 742 



Chloroform, effect of, on blood, 743 
effect of. on nervous system, 743 
in precipitate labor, 606 
in puerperal eclampsia, 684, 743 
in puerperal mania, 670, 743 
Chlorosis, in pregnancy, 225 
Chorion, formation of, 106 
Cicatrices, obstructing labor, 573 
Circulation, disorders of, in pregnancy, 225 

in foetus, 137 
Clitoris, 49 

hypertrophy of, 55 
Coccyx, 35 

Columnas rugarum, 51 

Compound or complicated presentations, 352 
Conception, 97 

in plural pregnancy, 191 
Constipation, in newly born child, 633 

in pregnancy, 224 
Convulsions, see Puerperal Eclampsia. 
Corpus luteum , differences between unimpreg- 
nated and impregnated, 83 
formation of, 80 
Cough, in pregnancy, 225 
Cramps, in labor, 275 

Crania bifida, as an obstruction to labor, 586 
Cranium, foetal, diameters of, 134 
fontanelles of, 134 
sutures of, 133 
vertex of, defined, 136 
Cranial planes, engagement of, at the brim, 

291 
Cranial presentations, 289 

analogy between face and, 317, 319, 323 
biparietal obliquity in, 288, 292, 296, 

297. See Appendix, 
bregmato-cotyloid, and fronto-cotyloid 

positions of, 306 
caput succedaneum in, 264, 295 
cause "of rotation of cranium in, 294, 301 
classification of, 290 
comparative frequency of the four, 31 1 
complicated with other presentations, 352 
engagement of cranial planes at brim in, 

291 
examination of fontanelles and sutures 

in, 292, 300, 303, 308 
first position in, 291 
second position in, 299 
third position in, 302 
fourth position in, 307 
head at the brim in, 291 
head at the outlet in, 298 
mechanism of labor in, 289, 303 
moulding of head in, 289. 308 
movement of restitution in, 298,300 
movement of rotation in, 295, 300, 304, 

307 
occipito-anterior positions in. 291 
occipito-posterior positions in, 291, 303 
occipitofrontal obliquity in, 291 
occipito posterior positions in, artificial 

rectification of, 31 1 
occipito-posterior positions in, fronto- 

anterior termination of, 306 
occipito-posterior positions, mechanism 

of labor in, 303 
occipito-posterior positions in, natural 

termination of, 304 
occipito-posterior positions, terminating 

in face presentations, 308 
other possible positions in, 311 



INDEX. 



755 



Cranial presentations, pelvic obliquity in, 297 

resume of. 302 

tabular comparison of face and, 324 

theories as to causation of, 128 
Cranioclast, Braun's, 534 

Simpson's, 534 
Craniotomy, 526 

canting the base of the skull in, 536 

conditions favorable to, 528 

conditions warranting, 527 

contrasted with turning, 519, 521 

cranial section by ecraseur in, 543 

extraction of the trunk in, 542 

in breech presentation. 542 

in puerperal eclampsia, 686 

operation of turning after, 535 

perforation in, 529 

question of, in deformities of the pelvis, 
460 

stages of, 529 

use of the cephalotribe in, 538, 544 

use of the craniotomy forceps in, 533 

use of the crotchet in, 531 

use of the osteotomist in, 534 

Van Huevel's forceps saw in, 543 
Craniotomy forceps, Meigs's, 534 

use of the, in craniotomy, 538 

use of the, in decapitation, 509 
Craniotomy scissors. Hodge's, 529 
Crede's method of delivering the placenta, 

282 
Crotchet, 504 

history of the, 505 

objections to use of the, 505 

the guarded, 505, 531 

uses of the. 505 

use of the, in craniotomy, 531 

use of the, in decapitation, 509 

use of double, 506 
Crowning, stage of, in labor, 265 
Crural phlebitis, see Phlegmasia Dolens. 
Cystocele, obstructing labor, 577 



Decapitation, 506, 543 

extraction of head in, 508 

extraction of trunk in, 507 

instruments used in, 506 

mode of operating in, 508 

stages of operation in, 507 

use of the forceps in, 508 
Decidua, formation of, 108 

reflexa, 110 

serotina. 110 

vera, 1 10 

in extra-uterine pregnancy, 197 
Deformities of pelvis, 442 

eequabiliter, justo-major and -minor, 450 

at the brim, 444 

at the outlet, 448 

Caesarian section in, 460 

causes of, 443 

classification of, 443 

effects of, 450 

effect of muscular action, in causing, 450 

exaggerated sacral curvature, 448 

flattening of the sacrum in, 448 

funnel-shaped pelvis, 448 

induction of premature labor in, 458, 560 

infantile type of pelvis, 449 

in malacosteon, 443, 446 

in rachitis, 443 



Deformities of pelvis, in the cavity, 447 

masculine type of pelvis, 449 

obliquely distorted pelvis, 447 

osteo-sarcoma, causing, 451 

spondylolisthesis, 450 

symptoms of, 452 

the result of disease or injury, 443 

treatment in, 457 

turning or craniotomy in, 459 

use of the forceps in, 458 

use of pelvimeters in, 453 
Dentition, 639 

disorders of, 641 

management of children during, 641 

odontitis in, 641 

order of eruption of teeth in, 640 

practice of lancing the gums in, 641 

process of, a guide to proper period for 
weaning, 637, 640 

reflex effects of. on system, 639 

symptoms of, 639 

treatment after, 639 
Diarrhoea, in pregnancy, 224 

inflammatory or dysenteric, in newly 
born child, 633 

simple or catarrhal, in newly born child, 
633 
Digestion, disorders of, in pregnancy, 220 
Digital examination, 158, 164 

in labor, 270, 274, 600, 606 

reflex effect of, as a cause of rupture of 
uterus, 434 
Diphtheria of puerperal wounds, see Puerperal 

Wounds. 
Displacements of uterus, 59, 67, 244, 251 

as a cause of uterine inertia, 596, 598 

obstructing labor, 572 
Dropsy, general, in pregnancy. 235 

of amnion, 236,240, 597, 599, 601 
Dysmenorrhoea, membranous, 200 
Dyspnoea, in pregnancy, 224 

Ecraseur, use of, in craniotomy, 543 
Ectopy, obstructing labor, 590 
Embryo, definition of term, 120 

demonstration of structures of, 108 

formation of, 101 
Embryo cell, formation of, 101 
Embryotomy, 526 

conditions warranting, 519, 527 
Embryulcia, 542 
Enteric fever, connection of, with puerperal 

fever, 691 
Ephemera or weid, 612 
Ergot, 601 

character of contractions caused by, 602 

dangers in use of, 603 

improper use of, a cause of rupture of 
uterus, 433 

in induction of labor, 564, 602 

mode of administering, 603 

natural history of, 601 

physiological effects of, 602 

rules for use of, in midwifery. 603 

use of, in distinguishing uterine tumors, 
602 

use of, in post-partum haemorrhage, 411, 
412 

use of, in uterine inertia, 600 
Ether, use of, in midwifery, 742 
Erysipelas, connection of, with puerperal 
fever, 690, 703 



756 



INDEX. 



Examination, vaginal, 158, 164, 270, 274, 600. 

606 
Excoriation of nipple, 624 
Excretions, disorders of, in pregnancy, 233 
Exomphalos, obstructing labor, 590 
External organs of generation, 48 
Extra-uterine pregnancy, 194 

causes of, 196 

development of membranes in, 197 

development of ovum in, 194, 196, 198 

sympathy of uterus in, 198 

symptoms of, 199 

symptoms of rupture of sac in, 201 

terminations of, 20 L 

treatment of, 203 

varieties of, 195 



Face presentations, 315 

analogy between cranial and, 315, 319, 
323 

caput succedaneum in, 316, 317 

causes of, 315 

classification of, 316 

diagnosis of, 316 

distinction between obstetrical and ana- 
tomical face in, 315 

first position in, 317 

second position in, 318 

third position in, 317 

fourth position in, 316 

mechanism of labor in, 316 

mento-antei ior positions in 316, 317 

mento-posterior positions in, 316,317 

inento-posterior positions, artificial recti- 
fication of. 321, 322 

mento-posterior positions, natural termi- 
nation of, 320 

movement of restitution in, 317 

movement of rotation in, 317, 318 

operative interference in, 322 

tabular comparison of cranial and, 324 

termination of occipito-posterior cranial 
positions in, 307 

use of the straight forceps in, 497 
Fallopian tubes, 65 
Fecundation, sue Conception. 
Feeding, artificial, of newly born child, 635 
Fillet, cases suitable for use of the, 503 

history of, 503 

mode of using, 504 

in breech presentations, 338," 503 

in turning, 616 
Fissure of nipple, 624 
Foetus, altitude of, in uterus, 128 

characteristics of monthly stages in de- 
velopment of, 125 

circulation in, 137 

definition of term, 120 

dimensions of mature, 127 

diseases of, 215 

diseases of. obstructing labor, 582 

fracture of bones of, 216 

functions of, 136 

length and weight of, at birth, 127 

movements of, observed by mother and 
accoucheur, 165, 166 

nutrition in, 141 

pulsation of, in pregnancy, 168 

pulsation of, in twin pregnancy, 170 

respiration in, 139 

secretions in, 142 



Foetus, signs of death of, 352 

spontaneous intra-uterine amputation of, 
216 

unusual development of, obstructing 
labor, 582 
Foetal heart, auscultation of, 168 

auscultation of, in twin pregnancy, 169 
Fontanelles of foetal cranium, 134 

examination of, in labor, 292, 293, 300, 
303, 307 

premature closure of, obstructing labor, 
587 
Foot presentations, diagnosis of, 334 

diagnosis of foot from hand in, 335 
Fossa navicularis, 49 
Fourchette, laceration of, 266, 279 
Fractures, causing deformities of pelvis, 452 

intra-uterine, 216, 587 
Frenulum pudendi, 49 
Forceps, 460 

application of the, 474. 476 
in dorsal position, 493 
Jenks on, 489 
to sides of pelvis, 486 

Chamber Jen's, 461 

circumstances requiring the use of the, 
472 

conditions essential to application of, 474 

craniotomy, 533 

Davis's. 466 

Elliot's, 469 

French, 462 

Harper's. 499 

history of, 460 

Hodge's, 466 

the long, 483 

long, application of. 486 

long, cases suitable for, 483, 485 

long, contrasted with turning, 519, 521 

long, mode of applying, 490 

long, modes of extraction by, 495 

long, necessity of double curve in, 483 

modes of action of the, 480 

mode of applying the, 480 

mode of extraction by the, 480 

modifications of the, 498 

placental, 384 

question of single verstis double curved, 
463, 464, 483, 499 

Radford's, 499 

Robertson's, 469 

Smith's, 469 

Simpson's, 471 

the short, 46^ 

short, cases suitable for, 463, 472 

the straight, 464, 465 

straight, reasons for preferring, 465 

straight, use of, in face presentations, 497 

use of, in breech presentations, 337, 341, 
497 

use of in decapitation, 509 

use of, in deformities of pelvis, 458 

use of, in funis presentations, 366 

use of, in occipito-posterior cranial posi- 
tions, 482 

use of, in placenta prsevia, 396 

use of, in puerperal eclampsia, 686 

use of, in uterine inertia, 601. 603 

use of long and short, relative dangers 
of, 485 

Wallace's, 468 

Ziegler's, 498 



INDEX. 



757 



Funis, see Umbilical Cord. 
Funis presentations, 355 

causes of, 356 

diagnosis of, 359 

postural method of treatment in, 364 

turning in, 366 

relation of, to other presentations, 356 

reposition by fingers and otherwise. 363 

rupture of membranes in, to be avoided, 
361 

special risks of, 359 

treatment in, 360 

use of forceps in, 366 
Funic souffle, 170 



Galactorrhoea, 615 

treatment of, 616 

varieties of, 616 
Galvanism, use of, in induction of premature 
labor, 569 

use of, in post-partum haemorrhage, 362 

use of, in uterine inertia, 412 
Gastrodynia, in pregnancy, 224 
Gastro-elytrotomy, 554 
Gastrotomy, 554 

cases requiring, 555 

in extra-uterine pregnancy, 204 

question of, in rupture of uterus, 439. 
440 

special dangers of, in midwifery, 555 
Gelatin of Wharton, 112 
Germinal spot, 78 

vesicle, 78 

function of, 99 
Glands, mammary, 55 

vulvo-vaginal, 53 
Goodell on accidental haemorrhage, 402 
Graafian vesicle, structure of, 76 
Gravid uterus, 144 

changes in os and cervix of, 159 

displacements of, 244 

involution of muscular fibres of. 146 

muscular fibres of, 144 

muscular layers of, 145 

progressive development, and anatomi- 
cal relations of, 147 
Gums, practice of lancing the, in dentition, 
641 



Haemorrhage, accidental, see Accidental 

Haemorrhage. 
Haemorrhage, after delivery, preceding ex- 
pulsion of placenta, 404 
distinction between accidental and un- 
avoidable, 387, 398, 401 
in abortion, 374. 376 
management of, in abortion, 382 
true post-partum, see Post-partum Haem- 
orrhage, 
unavoidable, see Placenta Praevia. 
Hand, examination of, in transverse presenta- 
tions, 343, 345 
diagnosis of, from foot, 334 
Hernial tumors, obstructing labor, 580 
Hidrosis, 704, 705 
Hydatidiform moles, 209 
pathology of, 210 
symptoms of, 211 
terminations of, 212 
treatment of, 213 



Hydrocephalus, foetal, 582 
diagnosis of, 582 

external and internal varieties, 583 
maternal mortality in, 584 
pelvic presentations with, 584, 585 
treatment in, 584 

Hydrorrhoea, 241 

Hydrothorax, foetal, obstructing labor, 586 

Hymen, 50 

imperforate, 55 
persistent, in labor, 573 

Hysterotomy, 545 

amount of contraction warranting, 546 
cases in which it is justifiable, 547 
causes of fatal result in, 553 
closure of the wound in, 551 
conditions favorable to success in, 548 
details of the operation, 549 
in deformities of the pelvis, 461 
history of, 545 

maternal mortality in, 547, 548 
removal of the placenta in, 551 
treatment after, 552 



Ichorrhsemia, 690 
Icterus neonatorum, 634 

Impaction in labor, distinction between " ar- 
rest "' and, 457 
Induction of premature labor, 558 
Barnes's process, 567 
conditions justifying, 559 
details of operation, 564 
dilatation of the os by tents, 565 
history of, 558 
in accidental or unavoidable hasinor- 

rhage, 562 
in excessive vomiting of pregnaney, 222, 

560 
in habitual death of foetus near full time, 

560 
introduction of elastic catheter in, 565 
in impaired general health of mother, 562 
methods of, 565 
nature and scope of, 559 
in pelvic contraction, 458, 560 
plugging or distending the vagina in, 565 
rupture of the membranes in. 565 
separation of the membranes in, 565 
to obviate puerperal eclampsia, 683 
use of ergot in, 564 
use of galvanism in, 569 
vaginal or uterine injections in, 566 
viability of child in. 559 
Inert labor, see Uterine Inertia. 
Insanity, see Puerperal Insanity. 
Intellectual faculties, aberrations of, in preg- 
nancy, 243 
Intestinal derangements, influence of on 

labor, 595, 601, 606 
Intestines, prolapse of, in rupture of uterus, 

438 
Inversion of uterus, 418 

as a cause of post-partum haemorrhage, 

407 
causes of, 420 
chronic cases of, 425, 426 
diagnosis of, 422 
distinctions between, and polypus, 408, 

424 
distinctions between, and simple pro- 
lapsus, 424 



758 



INDEX. 



Inversion of uterus, dragging on cord as a 

cause of, 420 
in unimpregnated state, 420 
irregular contraction of uterus as a cause 

of, 421 
management of adherent placenta in, 425 
mechanism of the displacement in, 422 
paralysis of the fundus, as a cause of, 421 
removal by ecraseur in, 429 
successive stages of, 419 
sustained elastic pressure in, 427 
symptoms of, 423 
Thomas's operation for the reduction of, 

429 
treatment in, 425 
treatment in chronic cases of, 427 
uterine inertia as a cause of, 421, 427 

Knee presentations, diagnosis of, 334 
Kiestein, 152 

Labia majora, 49 
Labia minora, 49 

hypertrophy of, 54, 575 
Labor, 252 

action of voluntary muscles in. 256, 264, 
273 

caput succedaneum in, 264 

causes of, 252 

cramps in thighs during, 275 

crowning, stage of, in, 256 

digital examination in, 270, 271, 274, 
600, &06 

duties of accoucheur in, 268 

effect of emotional causes on, 254 

first stage of, 257 

first stage, duration of, 263 

first stage, management of, 273 

first stage, rigor on termination of. 262 

first stage, termination of, 262 

functions of liquor amnii in. 261 

inert, see Uterine Inertia. 

influence of intestinal derangements on, 
595, 599. 606 

insanity of, see Puerperal Insanity. 

irregularities in the progress of, 594 

management of, 26S 

mechanism of, 284 

mechanism of dilatation of os and cervix 
in, 261 

mobility of articulations during, 30, 35, 
242 

natural lubrication of vagina in, 260 

obstructions to, $?e Obstructions to Labor. 

oedema of anterior lip of os in, 264, 275 

pains of, 258, 262, 264, 266 

perineum, dilatation of, 265 

perineum, laceration of, in, 266, 279 

perineum, rigidity of, in, 279 

perineum, support of, in, 277 

peristaltic action of uterus in, 256 

persistent hymen in, 573 

precipitate, fee Precipitate Labor. 

preliminary arrangements in, 269 

preparation of bed for, 274 

preparatory stage of, 257 

reflex function of spinal cord in, 255 

retention of urine in, 275 

rigidity of os in, 264, 276, 571 

rupture of membranes in, 262, 276 

second stage of, 265 

second stage, management of, 274 



Labor, second stage, termination of 266 

"show' 1 on termination of first stage, 
262 

stages of, 257 

third stage of, 266 

third stage, management of, 281 

use of stethoscope in, 276 
Labor pains, 258 

character of, in first stage, 262 

character of, in second st;ige, 264 

character of, in third stage, 266 

difference between true and false. 260 

effect of, on maternal pulse, 259 

effect of, on uterine souffle, 259 

false treatment of, 269 
Lactation, 612 

agalactia, 615 

disorders of, 618 

duration of, 617 

galactorrhcea, 615 

influence of menstruation on, 618 

influence of pregnancy on, 618 

insanity of, see Puerperal Insanity. 

management of, 616 

milk too rich, 617 

milk too watery, 617 

pain in mammae during, 614 

prejudicial effects of overfeeding in, 614 
Laparotomy, see. Gastrotomy. 
Leucorrhcea, 238 
Ligaments of ovaries, 65 

of pelvis, 39 

of uterus, broad, 63 

of uterus, posterior, 66 

of uterus, round, 64 

vesico-uterine, 65 
Ligature of limbs, in puerperal eclampsia, 

687 
Liquor amnii, 108 

evacuation of, in accidental hamorrhage, 
403 

evacuation of, in placenta praevia, 393 

functions of, in labor, 261 

management of, see Membranes. 
Lochia, 609 

management of the, 610 

nature and source of the, 609 



Malacosteon, 443, 445 

contrasted with rachitis, 444 
Mammae, application of child to, at fixed in- 
tervals, 613, 629 

changes in, during pregnancy, 153 

early application of child to, 283, 411, 
612, 613, 629 

inflammation and abscess of, 619 

management of, after delivery, 612 

pain in, during nursing, 614 

secretion of milk in, 154, 612 
Mammary abscess, varieties of, 620 

treatment of. 621 
Mammary glands, 55 
Mania, see Puerperal Insanity. 
Meatus urinarius. 49 

Mechanism, of dilatation of os and cervix in 
labor. 260 

of expulsion of placenta, 267 

of labor, 284 

of labor in breech presentations, 325, 327 

of labor in cranial presentations, 290, 303 

of labor in face presentations, 315 



INDEX, 



759 



Melancholia, see Puerperal Insanity. 
Membranes, artificial rupture of, in labor, 276 

artificial separation of, in induction of 
labor, 565 

development of, in extra-uterine preg- 
nancy, 197 

disposition of, in twin pregnancy, 191 

management of, in funis presentations, 
361 

management of, in puerperal eclampsia, 
686 

management of, in transverse presenta- 
tions, 343 

premature rupture of, as a cause of pre- 
cipitate labor, 605 

premature rupture of, as a cause of uter- 
ine inertia, 597 

rupture of, in induction of labor, 565 

separation of, in induction of labor, 565 

spontaneous rupture of, in labor, 261 

unusual thickness and resistance of, ob- 
structing labor, 594 
Menstruation, 87 

analogy between "rut" and, 88 

amount of discharge during, 9t 

cause of, 97 

character of discharge in, 92 

conditions influencing age at which first 
occurrence of, 89 

delayed, distinguished from abortion, 374 

duration of, 9 I 

duration of epoch of, 96 

influence of lactation on, 618 

irregularities in, 96 

phenomena attending first occurrence of 
88 

source of discharge in, 92 

suppression of, in pregnancy, 151 
Metria, 689 

Metritis, see Puerperal Metritis. 
Midwifery, defined, 33 

history of, 17 
Milk, escape of, from mammse, 614 

estimation of quality of, 615 617 

period for permitting other food than. 636 

secretion of, see Lactation. 

substitutes for breast-, 635. 637 

treatment when too rich or watery, 617 
Milk fever, 612 
Miscarriage, see Abortion. 
Missed labor, 215 
Moles, 206 

false, 206 

fleshy, 208 

hydatidiform, see Hydatidiform Moles. 

true. 207 
Mons veneris, 4S 
Monstrosities, 218, 590 

acephalic, 590 

anencephalic, 590 

ectopy, 590 

exomphalos. 590 

fusion of twins, 590 

by inclusion, 192, 592 

obstructing labor, 590 

the Siamese twins, 592 
Moral faculties, aberrations of, in pregnancy, 

243 
Morbus coxarius causing deformities of pel- 
vis. 452 
Morning sickness, of pregnancy, 152, 218, 
369, 560 



Nervous system, disorders of, in pregnancy, 

243 
Newly born child, 626 

administration of laxatives to the, 629, 

632 
application of, to mammae at fixed inter- 
vals. 613. 629 
artificial feeding of the, 635 
cleanliness of, 626, 628 
clothing of, 627 

congenital malformations of, 632 
desirability of mother nursing, 629 
diet and regimen of hired nurses of, 630 
difficulties of. in sucking, 631 
early application of, to mammoe, 283, 41 1, 

612, 613, 629 
food of, before mammary seeretion estab- 
lished, 629 
habitual constipation in, 633 
harelip in, 632 

imperforate anus or urethra, in the, 632 
inflammatory or dysenteric diarrhoea, in 

the, 633 
management of the, 626 
management of the bowels in the, 629, 632 
management of the cord in the, 626 
management of restlessness in the, 628 
necessity of air and light to the, 628 
nurse to be procured if artificial feeding 

fail, 636 
period for permitting ether food than 

milk, 636 
premature must be reared at the breast, 

635 
retention of urine in the, 632 
selection of hired nurses for the, 630 
simple or catarrhal diarrhoea in the, 633 
thrush in the, 634 
Nipple, changes in, during pregnancy, 154 

excoriation and fissure of, 624 
Nursing, application of child to mammse at 

fixed intervals. 613, 629 
artificial feeding of the child, 635 
desirability of rearing child at breast, 

629, 635 
early application of ehild to mammas, 

283. 411,612, 613, 629 
food of child before mammary secretion 

established. 629 
Liebig*s food for infants, 637 
nursing-bottles. 636 
premature child must be reared at breast, 

635 
substitutes for breast-milk, 635 
Nymphoe, see Labia Minora. 



Obstructions to labor, 570 

abnormal conditions of vulva and vagina, 

573 
anchylosis of foetal articulations, 586 
ascites of foetus, 586 
cicatrices from sloughing, 573 
coiling of cord round child, 593 
omnia bifida and spina bifida, 586 
eystocele, 578 
distension of bladder, 578 
distension of foetal bladder, 586 
dorsal displacement of the arm, 593 
ectopy, 590 

effects of uterine displacement, 572 
exomphalos, 590 



760 



INDEX. 



Obstructions to labor, fecal accumulation in 
rectum, 578 
fibrous, fatty, or encysted growths, 581 
gaseous distension from putrefaction, 586 
hernial tumors, 580 
hydrocephalus of foetus, 582 
hydrothorax of foetus, 586 
hymen, persistent, 573 
hypertrophy of anterior lip and cervix, 

275, 572 
hypertrophy of nymphse and preputium 

clitoridis, 575 
intra-uterine fracture, 216, 587 
locked twins, 588 

malignant disease of the canal, 581 
monstrosities, 590 
occlusion of os, 571 
ovarian tumors, 576 
plural pregnancy, 588 
polypoid tumors of uterus, 575 
premature closure of sutures and fonta- 

nelles, 587 
prolapse of the bladder, 578 
rigidity of the os, 264, 276, 570 
rigidity of the perineum, 279, 573 
scirrhus of rectum and rectocele, 577 
shortness of cord, 592 
spasmodic contraction of the cervix, 571 
tumors, renal, hepatic, etc., 586 
unusual development of foetus, 581 
unusual thickness and resistance of the 

membranes, 594 
urinary calculus, 579 
vaginal thrombus, 574 
Occipitoanterior cranial positions, mechan- 
ism of labor in, 290 
Occipito-frontal obliquity, in cranial presen- 
tations, 291 
Occipito-posterior cranial positions, artificial 
rectification of, 309 
bregmato-cotyloid termination in. 303 
fronto-cotyloid termination in, 306 
mechanism of labor in, 290, 303 
natural termination in, 304, 306 
terminations of in face presentation, 307 
Occlusion of os uteri, obstructing labor, 570 
Odontitis, 642 

Omphalomesenteric vessels, 105 
Organs of generation, external, 48 

internal, 58 
Os uteri, abscess and thrombus of lips of, in 
labor, 572 
changes in cervix and during pregnancy, 

159 
condition and appearance of unimpreg- 

nated, 61 
detection of, by speculum, 571 
hypertrophy of anterior lip of, in labor, 

275, 572 
mechanism of dilatation of in labor, 261 
mode of applying leeches to cervix and, 

738 
occlusion of, in labor, 570 
oedema of anterior lip of, in labor, 264, 

275 
relation of, to pelvic walls in pregnancy, 
162 
Osteomalacia, see Malacosteon. 
Osteosarcoma, causing deformities of pelvis, i 

451 
Osteotomist, use of the, in craniotomy, 534 
Ovaries, anatomy of, 75 



Ovaries, ligaments of, 65 
Ovarian pregnancy, 195 

Ovarian tumors, diagnosis of, from pregnancy, 
158 

obstructing labor, 576 
Ovulation, phenomena of, 79 
Ovum, anatomy of, 77 

contact of, with spermatozoa, 100 

development of, 101 

development of, in extra-uterine preg- 
nancy, 194, 197 

hEemorrhagic discharges from, 205, 207 

premature expulsion of, 367 
Oxytoxics, use of, in uterine inertia, 601 



Pain, abdominal, in pregnancy, 243 
of labor, see Labor Pains, 
mammary, during nursing, 614 
uterine, in pregnancy, 243 
Parametritis, 720 
Parovarium, 65 
Parturient canal, axis of, 42 
Parturition, cause of comparative difficulty in 
human species, 27 
forces which effect, 254 
in the primates, 27 
in the various races, 27 
mechanism of, 284 
post-mortem, 254 
Pelvic cellulitis, 720 

abscess in, treatment of, 740 

anatomy of pelvic cellular tissue with 

regard to, 733 
diagnosis between pelviperitonitis and, 

735 
mode of detecting pus in, 737 
treatment in, 737 
Pelvic measurements, 45 

conjugate, warranting the different op- 
erations, 557 
Pelvic presentations, see Breech Presenta- 
tions, 
comparative frequency of, 327 
special risks of, 329, 332, 335 
Pelvimetry, instrumental and manual, 452 
Pelvi-peritonitis, 695, 730 

abscess in, treatment of, 740 

Bernutz on, 733 

counter-irritation in, 740 

diagnosis between pelvic cellulitis and, 

735 
leeching in, 738 
mode of detecting pus in, 737 
mode of diagnosis in, 732 
treatment of, 737 
use of iodine in, 740 
use of mercury in, 739 
Pelvis, 33 

sequabiliter justo-raajor and -minor, 450 

angles of, 41, 46 

axis of the true, 42 

bones of, 34 

brim of, 43 

cavity of, 43 

comparative anatomy of, 23 

deformities of, see Deformities of Pelvis. 

development of, 46 

diameters of, 43, 45 

difference between male and female, 37 

floor of, 48 

funnel-shaped, 448 



INDEX. 



761 



Pelvis, human, a curved canal, 29 

inclination of, 41 

infantile type of, 450 

inflammation of articulations of, 242 

ligaments and articulations of, 89 

inalacosteon, 445 

masculine type of, 449 

mobilitv of articulations of, during labor, 
30, 36, 242 

obliquely distorted, 447 

outlet of, 44 

rachitic, 445 

soft structures connected with, 47 

true and false, 3(3 
Perforator, use of, in craniotomy, 529 

use of in decapitation, 510 
Perimetritis, 720, 784 
Perineum, 49 

dilatation of in labor, 205 

laceration oi\ 266, 280 

management of in labor, 277, 279 578 

treatment in threatened laceration of, 279 

treatment of rigidity of, in labor, 279, 578 
Peritonitis, see Puerperal Peritonitis. 
Peri-uterine hematocele, 741 
Peri-uterine phlegmon, see Pelvic Cellulitis. 
Phlebitis, see Puerperal Phlebitis. 

crural, see Phlegmasia Dolens. 
Phlegmasia dolens, 642 

after-effects of, 646 

antiseptic remedies in, 657 

causes of, 643 

causes of protracted convalescence in, 657 

causes of, unconnected with recent de- 
livery, 644, 652 

characteristic appearance of swelling in, 
646 

connection of with hemorrhagic cases, 
044 

connection of with puerperal fever, 700 

efficacy of blistering in, 055 

morbid anatomy of, 047 

most common in left leg. 044 

most common in pluriparse, 044 

nomenclature of, 643 

pathology of, 04 7, 051 

premonitory signs of, 645 

question of bloodletting in, 655 

question of contagiousness, 650 

symptoms of, 645 

tendency of, to attack other leg, 644 

terminations of, 047 

treatment of, 055 

use of bandages in, 656 

usual time of occurrence of, 644 
Phosphatio diathesis, in pregnancy, 38 
Phrenitis, to he distinguished from puerperal 

mania-, 862 
Placenta, 113 

abnormalities of, 405 

adherent, extraction of, 281 

adherent, management of, in inversion of 
uterus, 425 

anatomy of, 1 13 

apoplexy of, 213, 371 

artificial extraction of, in placenta pre- 
via, 396 

artificial separation of, in placenta prce- 
via, 899 

atrophy of, 214 

calcareous degeneration of, 214 

causes and treatment of retained, 404 



Placenta, causes of true adhesion of, 405 
Credc"s method of delivering, 282 
diseases of, 213, 370 
diseases of, causing abortion, 870 
disposition of, in twin pregnancy, 192 
dropsy of, 214 
expulsion of, 266 
expulsion of, in abortion, 8 77 
extraction of, 2S1 

extraction of, in rupture of uterus, 439 
fatty degeneration of, 213 
functions of, 1 16 
hypertrophy of, 214 
inflammation of, 214 
management of, in abortion. 2S8 
mechanism in expulsion of, 207 
removal of, in hysterotomy, 55 I 
results of disease in, 214, 870 
retention of, 281, 404 
retention of, in abortion, 377 
site of, in accidental haemorrhage, 402 
spontaneous expulsion of, in placenta 
pnvvia. 890, 890 

Placenta previa, 8S7 

artificial extraction of placenta in, 890 
artificial separation of placenta in, 898 
causes of, 8SS 

evacuation of liquor amnii in, 398 
idea of ancients as to nature of, 8S0 
natural terminations of complete and 

partial, 890, 897 
operation of turning in, 392, 894 
proclivity to recurrence of, 891 
spontaneous expulsion of placenta in, 390, 

43(1 
symptoms and signs of, 388 
treatment of, 'A\^ 1 
treatment, resume of, 400 
use of Barnes's bags in, :Wi\ 400 
use of forceps in, 396 
use of styptics after delivery in, 403 
use of vaginal plug or tampon in, 392, 

895 
varieties of complete and partial, 387 

Placental forceps, use of, 384 

Placental presentation, see Placenta Previa. 

Plethora in pregnancy, 228 

Plural pregnancy, 190 

as an obstruction to labor, 587 

duration of, 194 

mode of impregnation in, 191 

Polypus, fibroid, of uterus, distinctions be- 
tween, and inversion, 407, 423 
obstructing labor, 575 

Positions, classification of, 290 

Post-part urn hemorrhage, 404, 406 
astringents in, 4 13 
causes of, 400 

compression of aorta in, 413 
effects of rest and position in, 115 
fibroid tumors of uterus as a cause of, 407 
inversion of uterus as a cause of, 407 
manual pressure on uterus in, 41 I 
passage of hand into uterus in, III 
plugging in, 41 2 
reflex effect of cold in, 4 1 1 
symptoms of, 408 
tendency to reaction in, 416 

transfusion in, see Transfusion. 
treatment in, 410 
use of ergot in, 411, 413 
use of galvanism in, 412 



l'i 



762 



INDEX. 



Post-partum haemorrhage, use of Gariel's air 
pessary in, 412 

use of stimulants and opium in, 415 

use of styptics in, 413 

uterine inertia as a cause of, 405, 406 
Post-partum inflammations, connection of, 

with puerperal fever, 691, 707 
Precipitate labor, 604 

causes of, 605 

dangers of, 605 

from deficiency of resistance, 605 

influence of premature rupture of mem- 
branes on, 605 

influence of temperament on, 604 

treatment in, 606 

use of opium and chloroform in, 606 
Pregnancy, 144 

abdominal, 196 

abdominal pain in, 243 

albuminuria in, see Albuminuria. 

anteflexion and anteversion of uterus in, 
245 

appearance of abdomen during, 156 

ascites in, 234, 239 

ballottement in, 167 

cases of protracted, 178 

catarrh of bladder in, 233 

changes in mammae during, 153 

changes in os and cervix during, 159 

changes of umbilicus in, 156 

changes in urine during, 152 

chlorosis in, 225 

color of vagina in, 54, 158 

constipation in, 224 

diarrhoea in, 224 

differential diagnosis of abdominal tumors 
from, 157 

digestive disorders in, 151, 218, 369, 560 

digital examination in, 158, 164 

discoloration of skin in, 156 

diseases of, 218 

disorders of circulatory system in, 225 

disorders of locomotion in, 242 

disorders of nervous system in, 243 

disorders of respiration in, 224 

disorders of secretion and exeretion in, 
232 

duration of, 176 

duration of, in cows and mares, 177 

effects of, on the system, 674 

examination per ami in in, 165 

extra-uterine, see Extra- Uterine Preg- 
nancy. 

flattening of abdomen in, 157 

fcetal pulsation in, 168 

funic souffle in, 170 

influence of lactation on, 618 

insanity of. 659 

mode of calculating duration of, 183 

morning sickness of, 152, 218, 221, 369, 
560 

normal effect of, on the mind, 658 

ovarian, 195 

plethora in, 228 

plural, see Plural Pregnancy. 

quickening in, 165 

salivation in, 152, 232 

signs of, 149 

signs of certain, 175 

suppression of the cataraenia in, 151 

table showing signs of, at various epochs, 
175 



Pregnancy, treatment in digestive disorders 
of, 220. 560 

tubal, 195 

uterine pain in, 243 

uterine souffle in, 171 

vaginal examination in, 54, 158, 159,162 

vaginal pulse in, 159 
Premature labor, 385 

causes of, 386 

definition of term, 367 

effect of albuminuria in causing, 682 

induction of, see Induction of Premature 
Labor. 

influence of emotional causes on, 605 

symptoms of, 386 

treatment of, 386 
Presentation, compound or complicated, 352 

definition of term, 285, 289, 294 

of the arm or shoulder, see Transverse 
Presentations. 

of the breech, see Breech Presentations. 

of the brow, 322 

of the face, see Face Presentations. 

of the foot, 334 

of the knee, 334 

of the pelvis, see Pelvic Presentations. 

natural and faulty, 289 

of the vertex, see Cranial Presentations. 

relative frequency of various presenta- 
tions, 289 
Prolapse of uterus, distinctions between in- 
version and, 424 

in pregnancy, 244 
Pubiotoray, 556 
Puerperal angeioleucitis, 700 
Puerperal eclampsia, 672 

Barnes's theory of causation of, 674 

connection of., with acute Bright's dis- 
ease, 673, 675, 677 

definition of, 672 

detection of albumen in urine in, 679 

distinction of from other forms of eclamp- 
sia, 672, 677 

duration of tonic and clonic convulsions, 
and of coma in, 676 

formation of carbonate of ammonia in 
blood in, 678 

ligature of limbs in, 687 

maternal and fcetal mortality in, 681 

morbid anatomy of, 680 

mortality of treatment by bleeding and 
anaesthetics in, 685 

pathology of, 677 

premonitory symptoms and signs of, 675 

pressure on renal veins as a cause of albu- 
minuria in, 679 

question of bloodletting in, 684, 685 

question of induction of labor to obviate, 
683 

reflex sensibility in the causation of, 680 

rupture of the membranes in, 686 

symptoms of, 675 

theories as to connection between, and 
albuminuria, 678 

treatment after delivery in, 686 

treatment of during fit, and in different 
epochs, 684 

treatment, obstetrical, in, 686 

treatment, prophylactic, in, 683 

turning or craniotomy in, 686 

use of anaesthetic agents in, 684, 685, 743 

use of the forceps in, 686 



INDEX. 



763 



Puerperal eclampsia, uterine contractions as 
a cause of, 680 
fever, 687 

affections allied to, 691, 703 
causes of, 688, 700 
circumstances favoring propagation of, 

689, 701 

classification of diseases usually called, 

692 
condition of blood in malignant form of, 

709 
connection of, with angeioleucitis, 699 
connection of, with cadaveric poison, 703, 

717 
connection of, with enteric fever, 691 
connection of, with erysipelas, 690, 703 
connection of, with metritis, 697 
connection of, with peculiarities of puer- 
peral state, 690, 700 
connection of, with peritonitis, 695, 707 
connection of, with phlegmasia dolens, 

700 
connection of, with post-partum inflam- 
mations, 692, 707 
connection of with puerperal vaginitis, 

699 
connection of, with scarlatina, 691 
connection of, with septic absorption, 

690, 702, 707 

connection of, with typhus fever, 691, 703 

connection of, with uterine phlebitis, 697, 
708 

connection of, with variola, 691 

different forms of, 704, 707 

history of epidemics of, 704 

morbid anatomy of, 707 

nomenclature and classification of, 688, 
691 

question of contagiousness of, 701, 711, 
717 

question of specific nature of, 688 

question of tapping in, 717 

reasons for retaining term of, 691 

symptoms of, 705 

treatment of, 711 

treatment by bloodletting in, 711, 713 

treatment by emetics in, 716 

treatment, prophylactic, in, 711, 717 

treatment by purgatives in, 712, 714 

treatment by stimulants and tonics in, 
712, 717 

treatment, topical, in, 718 

use of antiseptics in, 718 

use of blisters in, 717 

use of calomel in, 716 

use of cold baths in, 717 

use of iodine in, 717 

use of the sulphites in, 716 

use of turpentine in, 716 

variations in type of, 704, 705, 711, 712, 
713 
Puerperal peritonitis, acute, sthenic, 714 

treatment of, 714 
Puerperal phlebitis, 698 

connection of, with puerperal fever, 698 

morbid anatomy of, contrasted with pu- 
erperal fever, 707 
Puerperal insanity, 737 

causes of, 659 

connection of, with albuminuria, 660, 668 

during labor, 659 

during lactation. 659 



Puerperal insanity, during pregnancy, 659 

hereditary predisposition in, 659 

influence of age on, 659 

most frequent in primiparae, 659 

nomenclature of, 658 

normal effect of pregnancy on the mind, 
658 

pathological theories of, 660 

prognosis of, 665, 667 

recurrence of attacks of, 672 

relative frequency of, 659 

seclusion and restraint in, 671 

suicidal impulse in, 671 

treatment of, 668 

true, 659 
Puerperal mania, 662 

essentially a disease of exhaustion. 662 

phrenitis to be distinguished from, 662 

prognosis of. 665, 667 

significance of a rapid pulse in, 664 

symptoms of, 663 

treatment of, 668 

treatment of, preventive, 668 
Puerperal melancholia, 666 

prognosis of, 667 

symptoms of, 666 

treatment of, 671 
Puerperal metritis, 697 

morbid anatomy of, contrasted with pu- 
erperal fever, 707 
Puerperal peritonitis, 695 

connection of, with acute tympanites, 696 

connection of, with puerperal fever, 695, 
696 

distinction between, and acute tympan- 
ites, 696 

false, 696 

morbid anatomy of, contrasted with pu- 
erperal fever. 707 

symptoms of ordinary, 695 

symptoms of severe, 695 
Puerperal pyaemia, 690, 693 
Puerperal state, connection of, with puer- 
peral fever, 690, 700 

management of the, 283, 607 

relation of the, to disease, 643 

sudden death in, 741 
Puerperal vaginitis, connection of, with pu- 
erperal fever, 698 
Puerperal wounds, diphtheria of, 719 

causes of. 726 

diagnosis of, 723 

nature of, 725 

pathological anatomy of, 723 

peritonitis in, 725 

prognosis of, 723 

prophylaxis of, 729 

symptoms of, 720 

treatment of, 727 
Pyrosis, in pregnancy, 224 



Quickening, 165, 185 



Rachitis, 443 

contrasted with malacosteon, 445 
Rectocele, obstructing labor, 578 
Repercussion, see Ballottement. 
Respiration, disorders of, in pregnancy, 224 
Restitution, movement of, in cranial presen- 
tations, 298 



764 



INDEX. 



Retroflexion of uterus in pregnancy, 246 
Retroversion of uterus in pregnancy, 246 
Rigidity of os uteri, 264, 276, 570 

causes of, 570 

from diseases, 570 

functional, 570 

occlusion of os in, 570 

treatment of, from disease, 571 

treatment of simple or functional, 571 
Rigidity of perineum, 279, 573 

treatment in, 573 
Rigor in labor, 262 

Rotation, movement of, in breech presenta- 
tions, 327, 332, 333 

movement of, in cranial presentations, 
293, 300 

movement of, in face presentations, 316, 
317 
Rupture of sac in extra-uterine pregnancy, 201 
Rupture of uterine ligaments, 437 
Rupture of uterus, 430 

atrophy of uterus as a cause of, 434 

causes of, 433 

during pregnancy, 430 

extraction of child in, 438 

extraction of placenta in, 439 

improper use of ergot as a cause of, 433 

premonitory symptoms of. 435 

prolapse of intestine in. 439 

question of gastrotomy in, 440 

question of turning in, 440 

reflex effect of digital examination as a 
cause of, 434 

relation of, to duration of labor, 433 

relative frequency of, in primiparse, 432 

rigidity of os as a cause of, 435 

signs of, 435 

sites of laceration in, 432 

treatment during pregnancy, 441 

treatment in, 437 

varieties of, 431 
Rupture of vagina, 436 
Rut, analogy between, and menstruation, 88 



Sacrum, 34 

exaggerated curvature of, 448 

flattening of the sacrum, 448 
Salivation, in pregnancy, 152, 232 
Scarlatina, connection of, with puerperal 

fever, 690 
Scirrhus of rectum, obstructing labor, 578 
Scybalae, as a cause of uterine inertia, 597 

obstructing labor, 578 
Secretions, disorders of, in pregnancy, 232 
Semen, composition of, 98 
Senses, special, affections of, in pregnancy, 

243 
Septic absorption, connection of, with puer- 
peral fever, 690, 703, 707 
Septicaemia, 690 

Shoulder presentations, see Transverse Pres- 
entations. 

comparative frequency of, 342 
Show, in labor, 262 

Skin, discoloration of, in pregnancy, 156 
Souffle, funic, 170 

uterine, 171 
Spermatozoa, contact of ovum with, 100 

development of, 98 

duration of life of, 179 
Spinal cord, reflex function of, in labor, 255 



Spondylolisthesis, 450 

Spina bifida, as an obstruction to labor, 586 
Spontaneous evolution, in transverse pres- 
entations, 346, 353 
Spontaneous expulsion, in transverse pres- 
entations, 347 
Stethoscope, use of, in labor. 276 
Stimulants, use of, in labor, 599 
Strychnia, use of, in uterine inertia, 604 
Styptics, use of, in post-partum haemorrhage, 

413 
Sucking, difficulties of the newly born child 

in, 631 
Sudden death in puerperal state, 741 
Superfecundation, 185 
Superfoetation, 185, 188, 200 
relation of, to twins, 185 
Suspended animation, treatment of, 280 
Sutures, of foetal cranium, 133 

examination of, in labor, 292, 300, 303, 

307 
premature closure of, obstructing la- 
bor, 587 
Symphysiotomy, 555 

history and nature of, 555 
results of, 556 



Teething, see Dentition. 
Thrombus, of lips of os uteri, 572 

of the vagina, 230, 574 
Thrush, in the newly born child, 634 

treatment of, 635 
Tumors, foetal, obstructing labor, 586 

maternal, obstructing labor, 575, 581 
Transfusion, 416 

''immediate" and "mediate" processes 
of, 417 
Transverse presentations, 341 

causes of, 342 

cephalic version in, 350 

combined version in, 350 

comparative frequency of, 342 

diagnosis of positions in, 343 

dorso-anterior and dorso-posterior posi- 
tions in, 344 

examination of arm in, 343, 345 

methods of operative interference in, 349 

podalic version in, 350 

premature rupture of membranes in, to 
be avoided, 343 

probable course of, in unaided cases, 345 

prolapse of arm in, 351 

signs of, before and during labor, 342 

spontaneous expulsion in, 347 

spontaneous evolution in, 346, 352 

treatment of, 349 
Triplets, 194 
Tubal pregnancy, 195 
Turning, 510 

bipolar version, 350, 522 

cephalic version, 518 

choice of hands in, 512 

circumstances rendering operation of, 
difficult, 513 

conditions requiring, and favorable to, 
511 

contrasted with craniotomy, 519, 521 

contrasted with the use of the long for 
ceps, 519, 521 

history of, 510 

in accidental hsemorrhage, 403 



INDEX. 



765 



Turning, in deformities of pelvis, 458, 459 

in funis presentations, 366 

in placenta praevia, 392, 394 

in puerperal eclampsia, 686 

in rupture of uterus, 440 

management of the case after, 518 

measurements admitting of, 519 

method of Robert Lee, 522, 523 

method of Wigand, 522 

mode of operating in, 512 

operation of. after craniotomy, 535 

pelvic version, 518 

podalic version, 511 

position of the child after, 517 

question of bringing down one leg or two 
in, 514 

question of, in contracted pelvis, 519 

question of, in funis presentations, 366 

special difficulties of, in deformities of 
pelvis, 521 

use of the noose or fillet in, 517 

various methods of, 511 
Twins, fusion of, 590 

locked, obstructing labor. 588 

the Siamese, 592 
Twin pregnancy, diagnosis of, 193 

disposition of membranes and placenta 
in, 191 

relation of, to superfcetation, 191, 193 

varieties of, 190, 191 
Tympanites, acute, distinctions between and 
puerperal peritonitis. 696 

symptoms of, 697 
Typhus fever, connection of, with puerperal 
fever, 691, 703 



Umbilical cord, anatomy of, 111 

coiling of, round foetus obstructing labor, 
592 

compression of, in breech presentations, 
336, 339 

diseases of, 215, 371 

diseases of. causing abortion, 371 

dragging on, a cause of inversion of 
uterus, 420 

knots on, 112, 365 

ligature of, 281 

ligature of, in twin pregnancy. 281 

management of the, after birth, 626 

presentation of the, see Funis Presenta- 
tions. 

shortness of, obstructing labor, 592 

vessels of, 106 
Umbilical vesicle, 104 
Umbilicus, changes of, in pregnancy, 156 
Unavoidable haemorrhage, see Placenta Pre- 
via. 
Unimpregnated uterus, 58 

anatomy of, 58 

axis of, 59 

condition and appearance of os in, 61 

difference between, and impregnated, 62, 
83 

displacements of, 67 

ligaments of, 62 
Uracbus, 105 
Urethra, 50 
Urine, changes in, during pregnancy, 152 

detection of albuminuria by examination 
of, 679 

retention of, after delivery, 609 



Urine, retention of, in labor, 275 

retention of, in newly born child, 632 

Urinary calculus, obstructing labor, 579 

Uterine appendages, inflammation of, 730 

Uterine inertia, 594 

as a cause of inversion of uterus, 420, 427 
as a cause of post-partum hasmorrhage, 

405, 406 
causes of, 595 

distended bladder or rectum in, 597 
influence of age and frequent pregnancy 

on, 596 
influence of climate and season, 596 
influence of emotional causes, 596 
influence of excessive uterine distension, 

597, 599, 600 
influence of irregular uterine action, 597 
influence of temperament, 596 
influence of uterine displacements, 596, 

598 
morbid conditions of the uterus in, 597, 

599 
treatment in. 599 
use of ergot in, 601 
use of the forceps in, 601, 603 
use of galvanism in, 412 
Wigand's and Scanzoni's classifications 
of, 598 

Uterine lymphatics, inflammation of, asso- 
ciated with puerperal fever, 700 

Uterine pain in pregnancy, 243 

Uterine phlebitis, see, Puerperal Phlebitis. 

Uterine souffle, 171 

effect of labor pains on, 258 

Uterine tumors, diagnosis of, from pregnancy, 
157 
use of ergot in distinguishing, 602 

Uterus, 58 

abnormal development of, 73 

atrophy of, as a cause of rupture of, 434 

attitude of foetus in, 128 

bloodvessels of, 71 

case of impregnation in double, 189 

difference between unimpregnated and 

impregnated. 61, 83 
displacements of, 59, 67, 244. 251 
displacements of, as a cause of inertia, 

596, 598 

displacements of, obstructing labor, 571 
fibrinous and haetnorrhagic casts of, 207 
fibroid tumors of, causing post-partum 

haemorrhage, 407 
gravid, see Gravid Uterus, 
inversion of, see Inversion of Uterus, 
irregular action of, causing inertia, 598 
ligaments of, 63, 66 
lymphatics and nerves of, 72 
malformations of, 73 
morbid conditions of, causing inertia, 

597. 598 

nervi-motor functions of, in labor, 254 
peristaltic action of, in labor, 256 
rupture of, see Rupture, 
spontaneous expulsion of, 437 
sympathy of, in extra-uterine pregnancy, 

198 
tumors of, obstructing labor, 575 
unimpregnated, see Unimpregnated Ute^ 

rus. 



Vagina, 51 



766 



INDEX. 



Vagina, abnormal conditions of, obstructing 
labor, 573 
change in color of, during pregnancy, 54, 

158 
double, 55 
examination by, in pregnancy, 54, 158, 

159, 162 
laceration of. 436 

natural lubrication of, in labor, 260 
plugging of, in abortion, 382 
plugging of, in placenta prjsvia, 392, 395 
plugging of, in post-partum haemorrhage, 

412 
the so-called Caesarian section through, 

555 
thrombus of, 230, 574 
Vaginal pulse, in pregnancy, 159 
Vaginismus, 55 
Vaginitis, granulosa, 238 

puerperalis, 698 
Varicose veins, in pregnancy, 230 
Variola, connection of, with puerperal fever, 

691 
Vectis, 500 

cases suitable for, 502 
history of, 500 



Vectis, mode of using, 501 

objections to use of, 501 

use of, in breech presentations, 337 
Version, cephalic, 350 

combined, see Bimanual Version. 

podalic, 350, 511 
Vertex, definition of term, 136 
Vestibule, 49 
Vitriform body, 108 
Voluntary muscles, action of, in labor, 256, 

264, 273 
Vomiting, in pregnancy, 152, 220, 369 

question of induction of labor in, 222, 560 

treatment of, 220, 223, 560 
Vulvo-vaginal follicles, sebaceous and mucip- 
arous, 53 
Vulvo-vaginal glands, 53 

Weaning, dentition a guide to proper period 

of, 637 
Weid or ephemera, 612 



Zona pellucida, 77 



HENEY O. LE^'S 

(late lea & blanchard's) 

CLASSIFIED O^^T^^I_.OC3TJE] 

OF 

MEDICAL AND SURGICAL PUBLICATIONS. 



In asking the attention of the profession to the works advertised in the following 
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TEEMS FOR 1878: 

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The Medical News and Library, both free of postage, j in advance. 

OR 

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terly (1150 pages per annum), with | &lx uollars 

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It is manifest that only a very wide circulation can enable so vast an amount of 
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(For "The Obstetrical Journal," see p. 22.) 



2 Henry C. Lea's Publications — (Am. Journ. Med. Sciences). 

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at the comparatively trifling cost of Six Dollars per annum. 

These periodicals are universally known for their high professional standing in their 
several spheres. 

I. 

THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 

Edited by ISAAC HAYS, M.D. 7 

is published Quarterly, on the first of January, April, July, and October. Each num- 
ber contains nearly three hundred large octavo pages, appropriately illustrated wher- 
ever necessary. It has now been issued regularly for over fifty years, during nearly 
the whole of which time it has been under the control of the present editor. Through- 
out this long period, it has maintained its position in the highest rank of medical 
periodicals both at home and abroad, and has received the cordial support of the en- 
tire profession in this country. Among its Collaborators will be found a large number 
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ORIGINAL COMMUNICATIONS 

full of varied and important matter, of great interest to a'll practitioners. Thus, during 
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highest standing in the profession throughout the United States* 

Following this is the "Review Department," containing extended and impartial 
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Thus, during the year 1875, the "Journal" furnished to its subscribers 98 Orig- 
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That the efforts thus made to maintain the high reputation of the "Journal" are 
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national exponent of medical progress : — 

America continues to take a great place in this 
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and Circular, Jan. 31, 1872. 

Of English periodicals the Lancet, and of American 
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regarded as necessities to the reading practitioner. — 
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The American Journal of the Medical Sciences 
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And that it was specifically included in the award of a medal of merit to the Pub- 
lisher in the Yienna Exhibition in 1873. 

The subscription price of the " American Journal of the Medical Sciences" has 
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II. 

THE MEDICAL NEWS AND LIBRARY 

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* Communications are invited from gentlemen in all parts of the country. Elaborate articles inserted 
by the Editor are paid for by the Publisher. 



rowed matter it contains, and has established for 
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is cultivated as a science. — Brit: and For. Med.-Chi- 
rurg. Review, April, 1S71. 

This, if not the best, is one of the best-conducted 
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present number is not by any means inferior to its 
predecessors. — London Lancet, Aug. 23, 1873. 

Almost the only one that circulates everywhere, 
all over the Union and in Europe. — London Medical 
Times, Sept. 5, 1S68. 



Henry 0. Lea ? s Publications— (Am. Journ. Med. Sciences). 3 

separately, so that they can be removed and bound on completion. In this manner 
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As stated above, the subscription price of the " Medical News and Library" is 
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found subjoined. It will thus be seen that during the last six months it has contained — 

Twenty-tJiree Articles on Anatomy and Physiology. 

Thirty-three " " Materia Medica and Tlierapeutics, 

Ninety -siac 6( t( Medicine. 

Ninety-two " ** Surgery. 

Sixty-one " " Midwifery and Gynaecology. 

Eleven, " (( Medical Jurisprudence and Toxicology 

Three * ( * ( Hygiene— 

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Henry C. Lea's Publications-— (Dictionaries). 



jyUNGLISON {ROBLEY), M.D., 

Late Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 

MEDICAL LEXICON; A Dictionary of Medical Science: Con- 
taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, 
Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters ; Formulas for 
Officinal, Empirical, and Dietetic Preparations ; with the Accentuation and Etymology of 
the Terms, and the French and other Synonymes ; so as to constitute a French as well as 
English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- 
ified and Augmented. By Richard J. Dunglison, M.D. In one very large and hand- 
some roval octavo volume of over 1100 pages. Cloth, $8 50; leather, raised bands, $7 50, 
{Just Issued.) 

The object of the author from the outset has not been to make the work a mere lexicon or 
dictionary of terms, but to afford, under each, a condensed view of its various medical relatione, 
and thus to render the work an epitome of the existing condition of medical science. Starting 
with this view, the immense demand which has existed for the work has enabled him, in repeated 
revisions, to augment its completeness and usefulness, until at length it has attained the positioB 
of a recognized and standard authority wherever the language is spoken. 

Special pains have been taken in the preparation of the present edition to maintain this en- 
viable reputation. During the ten years which have elapsed since the last revision, the additions 
to the nomenclature of the medical sciences have beengreaterthanperha.ps in any similar period 
of the past, and up to the time of his death the author labored assiduously to incorporate every- 
thing requiring the attention of the student or practitioner. Since then, the editor has been 
equally industrious, so that the additions to the vocabulary are more numerous than in any pre- 
vious revision. Especial attention has been bestowed on the accentuation, which will be found 
marked on every word. The typographical arrangement has been much improved, rendering 
reference much more easy, and every care has been taken with the mechanical execution. The 
work has been printed on new type, small but exceedingly clear, with an enlarged page, so that 
the additions have been incorporated with an increase of but little over a hundred pages, and 
the volume now contains the matter of at least four ordinary octavos. 

"VVe are glad to see a new edition of this invaluable 
work, and to find that it has been so thoroughly revised, 
and so greatly improved. The dictionary, in its pre- 



A book well known to our renders, and of which 
every American ought to be proud. When the learned 
author of the work passed away, probably all of us 
feared lest the book should not maintain its place 
in the advancing science whose terms it defines. For- 
tunately, Dr. Richard J. Dunglison, having assisted his 
father in the revision of several editions of the work, 
and having been, therefore, trained in the methods and 
imbued with the spirit of the book, has been able to 
edit it, not in the patchwork manner so dear to the 
heart of book editors, so repulsive to the taste of intel- 
ligent book readers, but to edit it as a work of the kind 
should be edited — to carry it on steadily, without jar 
or interruption, along the grooves of thought it has 
travelled during its lifetime. To show the magnitude 
of the task which Dr. Dunglison has assumed and car- 
ried through, it is only necessary to state that more 
than six thousand new subjects have been added in the 
present edition. "Without occupying more space with the 
theme, we congratulate the editor on the successful 
completion of his labors, and hope he may reap the well- 
earned reward of profit and honor. — Plnla. Med. Times, 
Jan. 3, 1874. 

About the first book purchased by the medical stu- 
dent is the Medical Dictionary. The lexicon explana- 
tory of technical terms is simply a sine qua non. In a 
science so extensive, and with such collaterals as medi- 
cine, it is as much a necessity also to the practising 
physician. To meet the wants of students and most 
physicians, the dictionary must be condensed while 
comprehensive, and practical while perspicacious. It 
was because Dunglison's met these indications that it 
became at once the dictionary of general use wherever 
medicine was studied in the English language. In no 
former revision have the alterations and additions been 
so great. More than six thousand new subjects and terms 
have been added. The chief terms have been set in black 
letter, while the derivatives follow in small caps; an 
arrangement which greatly facilitates reference. We 
may safely confirm the hope ventured by the editor 
" that the work, which possesses for him a filial as well 
as an individual interest, will be found worthy a con- 
tinuance of the position so long accorded to it as a 
standard authority." — Cincinnati Clinic, Jan. 10, 1874. 



sent form, is a medical library in itself, and one off 
which every physician should be possessed. — iV. Y. Med. 
Journal, Feb. 1874. 

With a history of forty years of unexampled success 
and universal indorsement by the medical profession of 
the western continent, it would be presumption in any 
living medical American to essay its review. No re- 
viewer, however able, can add to its fame; no captious 
critic, however caustic, can remove a single stone from 
its firm and enduring foundation. It is destined, as a 
colossal monument, to perpetuate the solid and richly 
deserved fame of Itobley Dunglison to coming genera- 
tions. The large additions made to the vocabulary, we 
think, will be welcomed by the profession as supplying 
the want of a lexicon fully up with the march of sci- 
ence, which has been increasingly felt for some years 
past. The accentuation of terms is very complete, and, 
as far as we have been able to examine it, very excel- 
lent. We hope it may be the means of securing greater 
uniformity of pronunciation among medical men. — At- 
lanta Med. and Surg. Journ., Feb. 1874. 

It would be mere waste of words in us to express 
out admiration of a work which is so universally 
and deservedly appreciated. The most admirable 
work of its kind in the English language. — Glasgow 
Medical Journal, January, 1866. 

A work to which there is no equal in the English 
language. — Edinburgh Medical Journal. 

Few works of the class exhibit a grander monument 
of patient research and of scientific lore. The extent 
jf the sale of this lexicon is sufficient to testify to its 
usefulness, and to the great service conferred by Dr. 
Robley Dunglison on the profession, and indeed on 
jthers, by its issue. — London Lancet, May 13, 1865. 

It has the rare merit that it certainly has no rival 
in the English language for accuracy and extent of 
references. — London Medical Gazette. 



TIOBLYN {RICHARD I).), M.D. 



A DICTIONARY OF THE TERMS USED IN MEDICINE AND 

THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hays, 
M.D., Editor of the "American Journal of the Medical Sciences." In one large royaJ 
12mo. volume of over 500 double-columned pages; cloth, $1 50 ; leather, $2 00. 
It is the best book of definitions we have, and ought always to be upon the student's table.— Southern 
Med and Surg. Journal. 



Henry C. Lea's Publications — (Manuals). 



R 



OZ) WELL {G.F.), F.R.A.S., frc. 
A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- 

istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, 
Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an Essay on the 
History of the Physical Sciences. In one handsome octavo volume of 694 pages, and 
many illustrations : cloth, $5. 



nTFILL {JOHN), M.D 



and 



C[31ITH {FRANCIS G.), M.D., 

Prof, of the Institutes of Medicine in the Univ. of Penna 

AN ANALYTICAL COMPENDIUM OF THE VARIOUS 

BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A 
new edition, revised and improved. In one very large and handsomely printed royal 12mo. 
volume, of about one thousand pages, with 374 wood cuts, cloth, $4; strongly "bound in 
leather, with raised bands, $4 75. 



The Compend ot'Drs. Neilland Smith is incompara- 
bly the most valuable work of its class ever published 
in this country. Attempts have been made in various 
quarters to squeeze Anatomy, Physiology, Surgery, 
the Practice of Medicine, Obstetrics, Materia Medica, 
and Chemistry into a single manual ; but the opera- 
tion has signally failed in the hands of all up to the 
advent of " Neill and Smith's' ' volume, which is quite 
a miracle of success. The outlines of the whole are 
admirably drawn and illustrated, and the authors 
are eminently entitled to the grateful consideration 



»f the student of every class. — N. 0. Med. and Sura. 
Tournal. 

There are but few students or practitioners of me- 
iicine unacquainted with the former editions of this 
ma,ssuming though highly instructive work. The 
yhole science of medicine appears to have been sifted, 
is the gold-bearing sands of El Dorado, and the pre- 
cioas facts treasured up in this little volume. A com- 
plete portable library so condensed that the student 
may make it his constant pocket companion. — West- 
cm Lancet. 



H 



ART8H0RNE {HENRY), M. D., 

Professor of Hygiene in the University of Pennsylvania. 

A CONSPECTUS OF THE MEDICAL SCIENCES; containing 

Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one lar»e 
royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations on 
wood. Cloth, $4 25 ; leather, $5 00. {Lately Issued.) 

aud the clear and instructive illustrations in some 
parts of the work.— American Journ. of Pharmacy, 
Philadelphia, July, 1874. 

The volume will be found useful, not only to stu- 
dents, but to many others who may desire to refresh 
their memories with the smallest possible expendi- 
ture of time.— N. Y. Med. Journal, Sept. 1874. 

The student will find this the most convenient and 
useful, book of the kind on which he can lay his 
hand. — Pacific Med. and Surg. Journ., Aug. 1S74. 



The work before us has already successfully assert- 
ed its claim to the confidence aud favor of the profes- 
sion ; it but remains for us to say that in the present 
edition the whole work has been fully overhauled 
and brought up to the present status of the science. — 
Atlanta Med. and Surg. Journal, Sept. 1874. 

The work is intended as an aid to the medical stu- 
dent, and as such appears to admirably fulfil its ob- 
j ect by its excellent arrangement, the full compilation 
f facts, the perspicuity and terseness of language, 



T UDLOW {J.L.), M.D. 
^A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 

Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and 
Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
and greatly extended and enlarged. With 370 illustrations. In one handsome royal 
12mo. volume of 816 large pages, cloth, $3 25 ; leather, $3 75. 
The arrangement of this volume in the form of question and answer renders it especially suit- 
able for the office examination of students, and for those preparing for graduation. 



fTANNER {THOMAS HAWKES), M.B.,8fc. 

A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 

NOSIS. Third American from the Second London Edition. Revised and Enlarged by 

Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, 

&c. In one neat volume small 1 2mo. , of about 375 pages, cloth, $1 50. 

*^* By reference to the " Prospectus of Journal" on page 3, it will be seen that this work is 

offered as a premium for procuring new subscribers to the "American Journal of the Medical 

Sciences." 

The objections commonly, and justly, urged again.-st 
the general run of "compends," "conspectuses," and 
other aids to indolence, are not applicable to this little 
volume, which contains in concise phrase just those 
practical details that are of most use in daily diag- 
nosis, but which the young practitioner finds it diffi- 
cult to carry always in his memory without some 
quickly accessible means of reference. Altogether, 
the book is one which we can heartily commend to 
those who have not opportunity for extensive read- 
ing, or who, having read much, still wish an occa- 
sional pracu« o1 reminder.— N. ¥. Med. Gazette, Nr.y. 
10, 1870. 



Taken as a whole, it is the most compact vade me- 
cum for the use of the advanced student and junior 
practitioner with which we are acquainted. — Boston 
Med. and Surg. Journal, Sept. 22, 1870. 

It contains so much that is valuable, presented in 
so attractive a form, that it can hardly be spared 
even in the presence of more full and complete works. 
Its convenient size makes it a valuable companion 
to the country practitioner, and if constantly car- 
ried by him, would often render him good service, 
and relieve many a doubt and perplexity.— Leaven- 
worth Med. Herald, July, 1870. 



Henry 0. Lea's Publications— (Anatomy), 



Q.RAY (HENRY), F.R.S., 

Lecturer on Anatomy at St. George's Hospital, London. 

ANATOMY, DESCRIPTIVE AND SURGICAL. The DrawiDgs by 

H. V. Caeter, M. D., late Demonstrator on Anatomy at St. George's Hospital ; the Dissec- 
tions jointly by the Author and Dr. Carter. A new American, from the fifth enlarged 
and improved London edition. In one magnificent imperial octavo volume, of nearly 900 
pages, with 465 large and elaborate engravings on wood. Price in cloth, $6 00 ; lea- 
ther, raised bands, $7 00. (Just Issued.) 
The author has endeavored in this work to cover a more extended range of subjects than is cus- 
tomary in the ordinary text-books, by giving not only the details necessary for the student, but 
also the application of those details in the practice of medicine and surgery, thus rendering it both 
a guide for the learner, and an admirable work of reference for the active practitioner. The en • 
gravings form a special feature in the work, many of them being the size of nature, nearly ali 
original, and having the names of the various parts printed on the body of the cut, in place of 
figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to 
refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with 
a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
essential use to all physicians who receive students in their offices, relieving both preceptor and 
pupil of much labor in laying the groundwork of a thorough medical education. 

Notwithstanding the enlargement of this edition, it has been kept at its former very moderate 
price, rendering it one of the cheapest works now before the profession. 



The illustrations are beautifully executed, and ren- 
der this work an indispensable adjunct to the library 
of the surgeon. This remark applies with great force 
to those surgeons practising at a distance from our 
large cities, as the opportunity of refreshing their 
memory by actual dissection is not always attain- 
able.— Canada Med. JovJrnal, Aug. 1870. 

The work is too well known and appreciated by the 
profession to need any comment. No medical man 
can afford to be without it, if its only merit were to 
serve as a reminder of that which so soon becomes 
forgotten, when not called into frequent use, viz., the 
relations and names of the complex organism of the 
human body. The present edition is much improved. 
—California Med. Gazette, July, 1870. 

Gray's Anatomy has been so long the standard of 
perfection With every student of anatomy, that we 
need do no more than call attention to the improve- 
ment in the present edition.— Detroit Review of Med. 
and Pharm., Aug. 1870. 



From time to time, as successive editions have ap- 
peared, we have had much pleasure in expressing 
the general judgment of the wonderful excellence of 
Gray's Anatomy. — Cincinnati Lancet, July, 1870. 

Altogether, it is unquestionably the most complete 
and serviceable text-book in anatomy that has ever 
been presented to the student, and forms a striking 
contrast to the dry and perplexing volumes on the 
same subject through which their predecessors strug- 
gled in days gone by. — N. ¥. Med. Record, Jane 15, 
1870. 

To commend Gray's Anatomy to the medical pro- 
fession is almost as much a work of supererogation 
as it would be to give a favorable notice of the Bible 
in the religious press*. To say that it is the most 
complete and conveniently arranged text-book of its 
kind, is to repeat what each generation of students 
has learned as a tradition of the elders, and verified 
by personal experience. — N Y. Med. Gazette, Dec. 
17, 1870. 



S 



MITH [HENRY H.), M.D., and JJORNER ( WILLIAM E.), M.I)., 

Prof, of Surgery in the Univ. of Penna. , &e. Late Prof, of Anatomy in the Univ. ofPenna., Ac. 

AN ANATOMICAL ATLAS, illustrative of the Structure of the 

Human Body. In one volume, large imperial octavo, cloth, with about six hundred and 

fifty beautiful figures. $4 50. 
The plan of this Atlas, which renders it so pecu- 1 the kind that has yot appeared ; and we must add, 
liarly convenient for the student, and its superb ar- | the very beautiful manner in which it is "got up," 
tistical execution, have been already pointed out. We j is so creditable to the country as to be flattering to 
must congratulate the student upon the completion our national pride.— American MedicalJournal. 
of this Atlas, as it is the most convenient work of I 



UHARPEY 1 WIT juIAM), M.D., and Q UAIN [JONES fr RICHARD). 
HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph 

Leidy, M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two 
large octavo volumes, of about 1300 pages, with 511 illustrations; cloth, $6 00. 
The very low price of this standard work, and its completeness in all departments of the subject, 
should command for it a place in the library of all anatomical students. 



fJODGES [RICHARD M.), M.D., 

Late Demonstrator of Anatomy in the Medical Department of Harvard University. 

PRACTICAL DISSECTIONS. Second Edition, thoroughly revised. In 

one neat royal 12mo. volume, half-bound, $2 00. 
The object of this work is to present to the anatomical student a clear and concise description 
of that which he is expected to observe in an ordinary couise of dissections. The author has 
endeavored to omit unnecessary details, and to present the subject in the form which many years' 
experience has shown hfci to be the most convenient and intelligible to the student. In the 
revision of the present edition, he has sedulously labored to render the volume more worthy of 
the favor with which it has heretofore been received. 



HORNER'S SPECIAL ANATOMY AND HISTOLOGY. I In 2 vols. 8vo., of over 1000 pages, with more thao 
Eighth edition, extensively revised and modified. I 300 wood-cuts; cloth, $6 00. 



Henry C. Lea ? s Publications— {Anatomy). 



TffllLSON {ERASMUS), F.R.S. 

A SYSTEM OF HUMAN ANATOMY, General and Special. Edited 

by W. H. G-obbecht, M. D., Professor of General and Surgical Anatomy in the Medical Col- 
lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. la 
one large and handsome octavo volume, of over 600 large pages; cloth, $4 00; leather, 
$5 00. 
Hie publisher trusts that the well-earned reputation of this long-established favorite will be 
more than maintained by the present edition. Besides a very thorough revision by the author, it 
has been most carefully examined by the editor, and the efforts of both have been directed to in- 
troducing everything which increased experience in its use has suggested as desirable to render it 
a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana- 
tomy. The amount of additions which it has thus received may be estimated from the fact thai 
fcho present edition contains over one-fourth more matter than the last, rendering a smaller type 
and an enlarged page requisite to keep the volume within a convenient size. The author has not 
only thus added largely to the work, but he has also made alterations throughout, wherever there 
appeared the opportunity of improving the arrangement or style, so as to present every fact in its 
most appropriate manner, and to render the whole as clear and intelligible as possible. The editor 
has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased 
the number of illustrations, of which there are about one hundred and fifty more in this edition 
than in the last, thus bringing distinctly before the eye of the student everything of interest or 
importance. 

TIE ATE [CHRISTOPHER), F. R. C. S., 

•*■-*■ Teacher of Operative Surgery in University College, London. 

PRACTICAL ANATOMY: A Manual of Dissections. From the 

Second revised and improved London edition. Edited, with additions, by W. W. Keen, 

M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. 

In one handsome royal 12mo. volume of 578 pages, with 247 illustrations. Cloth, $6 50 ; 

leather, $4 00. {Lately Published.) 
Dr. Keen, the American editor of this work, in his 
preface, says: "In presenting this American edition 
of 'Heath's Practical Anatomy,' 1 feel that I have 
been instrumental in supplying a want long felt for 
a real dissector's manual," and this assertion of its 
editor we deem is fully justified, after an examina- 
tion of its contents, for it is really an excellent work. 
Indeed, we do not hesitate to say, the best of its class 
with which we are acquainted ; resembling Wilson 
In terse and clear description, excelling most of the 
eo-called practical anatomical dissectors in the scope 
of the subject and practical selected matter. . . . 
In reading this work, one is forcibly impressed with 
the great pains the author takes to impress the sub- 
j ect upon the mind of the student. He is full of rare 
and pleasing little devices to aid memory in main- 



taining its hold upon the slippery slopes of anatomy. 
— St. Louis Med. and Surg. Journal, Mar. 10, 1871. 

It appears to us cartain that, as a guide in dissec- 
tion, and as a work containing facts ot anatomy in 
brief and easily understood form, this manual is 
complete. This work contains, also, very perfect 
illustrations of parts which can thus be more easily 
rnderstood and studied; in this respect it compares 
favorably with works of much greater pretension. 
Such manuals of anatomy are always ravorite works 
with medical students. We would earnestly recom- 
mend this one to their attention; it has excellences 
which make it valuable as a guide in dissecting, as 
well as in studying anatomy. — Buffalo MedAcal and 
SurgicalJour rial, Jan. 1871. 



BELLAMY [E.) , F.R. C.S. 

THE STUDENT'S GUIDE TO SURGICAL ANATOMY: A Text- 

Book for Students preparing for their Pass Examination. With engravings on wood. In 
ona handsome royal 12mo. volume. Cloth, $2 25. {Just Issued.) 

We welcome Mr. Bellamy's work, as a contribu- 
tion to the study of regional anatomy, of equal value 
to the student and the surgeon. It is written m a 
clear and concise style, and its practical suggestions 
add largely to the interest attaching to its technical 
details — Chicago Med. Examiner, March 1, 1874. 

We cordially congratulate Mr. Bellamy upon hav- 
ing produced it. — Med. Times and Qaz. 



We cannot too highly recommend it.— Student's 
■Journal. 

Mr. Bellamy has spared no pains to produce a real- 
ly reliable student's guide to surgical anatomy — one 
which all candidates for surgical degrees may cm- 
suit with advantage, and which posseses much ori- 
ginal matter — Med. Press and Circular. 



M: 



ACLISE [JOSEPH). 

SURGICAL ANATOMY. By Joseph Maclise, Surgeon. In one 

volume, very large imperial quarto; with 68 large and splendid plates, drawn in the best 
style and beautifully colored, containing 190 figures, many of them the size of life; together 
with copious explanatory letter-press. Strongly and handsomely bound* in cloth. Price 
$14 00. 

,$ions have hitherto, we think, been given. While 
he operator is shown every vessel and nerve where 
<in operation is contemplated, the exact anatomist is 
refreshed by those clear and distinct dissection,.-, 
which every one must appreciate who has a particle 
of enthusiasm. The English medical press has quite 
exhausted the words of praise, in recommending this 
admirable treatise. — Boston Med. and Surg. Journ. 



We know of no work on surgical anatomy which 
«an compete with it. — Lancet. 

The work of Maclise on surgical anatomy is of the 
highest value. In some respects it is the best publi- 
cation of its kind we have seen, and is worthy of a 
place in the library of any medical man, while the 
student could scarcely make a better investment than 
this. — The Western Journal of Medicine and Surgery. 

No such lithographic illustrations of surgical re- 



H 



ARTSHORNE [HENRY], M.D., 

Professor of Hygiene, etc , in the Univ. ofPenna. 

HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second Edi- 
tion, revised. In one royal 12mo. volume, with 220 wood-cuts ; cloth, $1 75. {Just Issued.^ 



8 



Henry C. Lea's Publications — (Physiology). 



MARSHALL {JOHN), F. R. S., 

'*£*- Professor of Surgery in University College, London, &c. 

OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE. 

With Additions by Francis Gurnet Smith, M. D., Professor of the Institutes of Medi- 
cine in the University of Pennsylvania, Ac. With numerous illustrations. In one large 
and handsome octavo volume, of 1026 pages, cloth, $6 50 ; leather, raised bands, $7 50. 

tive, with which we are acquainted. To speak oi 
this work in the terms ordinarily used on snch occa- 
sions would not be agreeable to ourselves, and would 
fail to do j ustice to its author. To write such a book 
requires a varied and wide range of knowledge, con- 
siderable power of analysis, correct judgment, skill 
in arrangement, and conscientious spirit. — London 
Lancet, Feb. 22, 1868. 

There arefew, if any, more accomplished anatomists 
and physiologists than the distinguished professor of 
surgery at University College ; and he has long en- 
joyed the highest reputation as a teacher of physiol- 
ogy, possessing remarkable powers of clear exposition 
and graphic illustration. We have rarely the plea- 
sure of being able to recommend a text-book so unre- 
servedly as this.— British Med. Journal, Jar . 25, 1868. 



In fact, in every respect, Mr. Marshall has present- 
ed us with a most complete, reliable, and scientific 
work, and we feel that it is worthy our warmest 
commendation.— St. Louis Med. Reporter, Jan. 1869. 

We doubt if there is in the English language any 
compend of physiology more useful to the student 
than this work. — St. Louis Med. and Surg. Journal, 
Jan. 1869. 

It quite fulfils, in our opinion, the author's design 
of making it truly educational in its character — which 
Is, perhaps, the highest commendation that can be 
asked. — Am. Journ. Med. Sciences, Jan. 1869. 

We may now congratulate him on having com- 
pleted the latest as well as the best summary of mod- 
ern physiological science, both human and compara- 



flARP ENTER [WILLIAM B.), M.D., F.R.S., 

*-^ Examiner in Physiology and Comparative Anatomy in the University of London. 

PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- 
cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A ne~w 
American from the last and revised London edition. With nearly three hundred illustrations. 
Edited, with additions, by Francis Gurney Smith, M. D., Professor of the Institutes of 
Medicine in the University of Pennsylvania, Ac. In one very large and beautiful octavo 
volume, of about 900 large pages, handsomely printed; cloth, $5 50 ; leather, raised bands, 
$6 50. 

We doubt not it is destined to retain a strong hold 
on public favor, and remain the favorite text-book in 
our colleges. — Virginia Medical Journal. 



With Dr. Smith, we confidently believe "that the 
present will more than sustain the enviable reputa- 
tion already attained by former editions, of being 
one of the fullest and most complete treatises on the 
subject in the English language." We know of none 
from the pages of which a satisfactory knowledge of 
the physiology of the human organism can be as well 
obtained, none better adapted for the use of such as 
take up the study of physiology in its reference to 
the institutes and practice of medicine. — Am. Jour. 
Med. Sciences. 



The above is the title of what is emphatically tht 
great work on physiology ; and we are conscious that 
it would be a useless effort to attempt to add any- 
thing to the reputation of this invaluable work, and 
can only say to all with whom our opinion has any 
influence, that it is our authority. — Atlanta Med. 
Journal. 



DI THE SAME AUTHOR. 

PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New Ameri- 

can, from the Fourth and Revised London Edition. In one large and handsome octavo 
volume, with over three hundred beautiful illustrations Pp.752. Cloth, $5 00. 
As a complete and condensed treatise on its extended and important subject, this work becomea 
a necessity to students of natural science, while the very low price at which it is offered places it 
within the reach of all. 



JTIRKES ( WILLIAM SENHOUSE), M.D. 

A MANUAL OF PHYSIOLOGY. Edited by W. Morrant Baker, 

M.D., F.R.C.S. A new American from the eigbth and improved London edition. With 
about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- 
ume. Cloth, $3 25; leather, $3 75. {Lately Issued.) 
Kirkes' Physiology has long been known as a concise and exceedingly convenient text-book, 
presenting within a narrow compass all that is important for the student. The rapidity with 
which successive editions have followed each other in England has enabled the editor to keep it 
thoroughly on a level with the changes and new discoveries made in the science, and the eighth 
edition, of which the present is a reprint, has appeared so recently that it may be regarded as 
the latest accessible exposition of the subject. 



On the whole, there is very little in the book 
which either the student or practitioner willnotfind 
of practical value and consistent with our present 
knowledge of this rapidly changing science ; and we 
have no hesitation in expressing our opinion that 
this eighth edition is one of the best handbooks on 
physiology which we have in our language. — N. Y. 
Med. Record, April 15, 1873. 

This volume might well be used to replace many 
of the physiological text-books in use in this coun- 
try. It represents more accurately than the works 
of Dalton or Flint, the present state of our knowl- 
edge of most physiological questions, while it is 
much less bulky and far more readable than the lar- 



ger text-books of Carpenter or Marshall. The book 
is admirably adapted to be placed in the hands of 
students. — Boston Med. and Surg. Journ., April 10, 
1873. 

In its enlarged form it is, in our opinion, still the 
best book on physiology, most useful to the student. 
—Phila. Med. Times, Aug. 30, 1873. 

This is undoubtedly the best work for students of 
physiology extant. — Cincinnati Med. News, Sept. '73. 

It more nearly represents the present condition of 
physiology than any other text-book on the subject. — 
Detroit Rev. of Med. Pharm., Nov. 1873. 



Henry C. Lea's Publications— (Physiology). 9 

f)ALTON {J. C), M.D., 

-*"- , Professor of Physiology in the College of Physicians and Surgeons, ITew York, &c. 

A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use 

of Students and Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, 
with three hundred and sixteen illustrations on wood. In one very beautiful octavo vol- 
ume, of over 800 pages. Cloth, $5 50 ; leather, $6 50. (Now Ready.) 

From the Preface to the Sixth Edition. 

In the present edition of this book, while every part has received a careful revision, the ori- 
ginal plan of arrangement has been changed only so far as was necessary for the introduction of 
new material. Although the whole field of physiology has been cultivated, of late years, with 
unusual industry and success, perhaps the most important advances have been made in the two 
departments of Physiological Chemistry and the Nervous System. The number and classification 
of the proximate principles, more especially, and their relation to each other in the process of 
nutrition, have become, in many respects, better understood than formerly ; though it is evident 
that this fundamental part of physiology is to receive, in the future, modifications and additions 
of the most valuable kind. 

The additions and alterations in the text, requisite to present concisely the growth of positive 
physiological knowledge, have resulted in spite of the author's earnest efforts at condensation, 
in an increase of fully fifty per cent, in the matter of the work. A change, however, in the ty- 
pographical arrangement has accommodated these additions without undue enlargement in the 
bulk of the volume. 

The new chemical notation and nomenclature are introduced into the present edition, as hav 
ing now so generally taken the place of the old, that no confusion need result from the change. 
The centigrade system of measurements for length, volume, and weight, is also adopted, these 
measurements being at present almost universally employed in original physiological investiga- 
tions and their published accounts. Temperatures are given in degrees of the centigrade scale, 
usually accompanied by the corresponding degrees of Fahrenheit's scale, inclosed in brackets. 
New York, September, 1875. 

A few notices of the previous edition are subjoined. 
The fifth edition of this truly valuable work on 
Human Physiology comes to us with many valuable 
Improvements ana additions. As a text-book of 



physiology the work of Prof. Dalton has long been 
well known as one of the best which could be placed 
in the hands of student or practitioner. Prof. Dalton 
has, in the several editions of his work heretofore 
published, labored to keep step with the advancement 
In science, and the last edition shows by its improve- 
ments on former ones that he is determined to main- 
tain the high standard of his work. We predict for 
the present edition increased favor, though this work 
has long been the favorite standard. — Buffalo Med. 
and Surg. Journal, April, 1872. 

An extended notice of a work so generally and fa- 
vorably known as this is unnecessary. It is justly 
regarded as one of the most valuable text-books on 
the subject in the English language. — St. Louis Med. 
Archives, May, 1872. 

We know no treatise in physiology so clear, com- 
plete, well assimilated, and perfectly digested, as 
Balton's. He never writes cloudily or dubiously, or 

in mere quotation. He assimilates all his material, | ical Record, April, 1872, 
and from it constructs a homogeneous, transparent 



argument, which is always honest and well informed, 
and hides neither truth, ignorance, nor doubt, so far 
as either belongs to the subject in hand. — Brit. Med. 
Journal, March 23, 1672. 



Dr. Dalton's treatise is well known, and by many 
highly esteemed in this country. It is, indeed, a good 
elementary treatise on the subject it professes to 
teach, and may safely be put into the hands of Eng- 
lish students. It has one great merit — it is clear, and, 
on the whole, admirably illustrated. The part we 
have always esteemed most highly is that relating 
to Embryology. The diagrams given of the various 
stages of development give a clearer view of the sub- 
ject than do those in general use in this country ; and 
the text may be said to be, upon the whole, equally 
clear. — London Med. Times and Gazette, March 23, 
1872. 

Professor Dalton is regarded justly as the authority 
in this country on physiological subjects, and the 
fifth edition of his valuable work fully justifies tha 
exalted opinion the medical world has of his labors. 
This last edition is greatly enlarged.— Virginia Clin- 



D 



UNGLISON {ROBLEY), M.D., 

Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 

HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and 

extensively modified and enlarged, with five hundred and thirty-two illustrations. In two 
large and handsomely printed octavo volumes of about 1500 pages, cloth, $7 00. 



JEH31ANN{C. O.). 

PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- 

tion by George E Bay, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of 
Chemistry in the Medical Department of the University of Pennsylvania, with illustrations 
selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Com- 
plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two 
hundred illustrations, cloth, $8 00. 

ry 7 THE SAME A UTEOR. 

MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the 

German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory 
Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsyl- 
vania. With illustrations on wood. In one very handsome octavo volume of 336 pages, 
cloth, $2 25. 



10 



Henry C. Lea's Publications — (Chemistry), 



ATTFIELD {JOHN), Ph.D., 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, &c. 

CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL 5 

including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles 
of the Science, and their Application to Medicine and Pharmacy. Fifth Edition, revised 
by the author. In one handsome royal I2mo. volume ; cloth, $2 75 ; leather, $3 25. 
(Lately Issued.) 

engaged in medicine and pharmacy, and we heartily 
commend it to our readers. — Canada Lancet, Oct. 
1871. 



No other American publication with which we are 
acquainted covers the same ground , or does it so well. 
In addition to an admirable expose" of the facts and 
principles of general elementary chemistry, the au- 
thor has presented us with a condensed mass of prac- 
tical matter, just such as the medical student and 
practitioner needs. — Cincinnati Lancet, Mar. 1874. 

We commend the work hearlily as one of the best 
text-books extant for the medical student. — Detroit 
Rev. of Med. and Pharm., Feb. 1872. 

The best work of the kind in the English language. 
— N. Y. Psychological Journal, Jan. 1S72. 

The work is constructed with direct reference to 
the wants of medical and pharmaceutical students ; 
and, although an English work, the points of differ- 
ence between the British and United States Pharma- 
copoeias are indicated, making it as useful here as in 
England. Altogether, the book is one we can heart- 
ily recommend to practitioners as well as students. 
—N. T. Med. Journal, Dec. 1871. 

It differs from other text-books in the following 



"When the original English edition of this work was 
published, we had occasion to express our high ap- 
preciation of its worth, and also to review, in con- 
siderable detail, the main features of the book. As 
the arrangement of subjects, and the main part of 
the text of the present edition are similar to the for- 
mer publication, it will be needless for us to go over 
the ground a second time ; we may, however, call at- 
tention to a marked advantage possessed by the Ame- 
rican work— we allude to the introduction of the 
chemistry of the preparations of the United States 
Pharmacopoeia, as well as that relating to the British 
authority. — Canadian Pharmaceutical Journal, 
Nov. 1S71. 

Chemistry has borne the name of being a hard sub- 
ject to master by the student of medicine, and 
chiefly because so much of it consists of compoundn 
onlv of interest to the scientific chemist ; in this work 



particulars : first, in the exclusion of matter relating such portions are modified or altogether left out, and 
to compounds which, at present, are only of interest J in the arrangement of the subject-matter of the work, 
to the scientific chemist; secondly, in containing the practical utility is sought after, and we think fully 
chemistry of every substance recognized officially or attained. We commend it for its clearness and order 
in general, as a remedial agent. It will be found a to both teacher and pupil.— Oregon Med. and Surff. 
most valuable book for pupils, assistants, and others Reporter, Oct. 1871. 



F 



OWNES {GEORGE), Ph.D. 
A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 

Practical. With one hundred and ninety-seven illustrations. A new American, from the 
tenth and revised London edition. Edited by Robert Bridges, M. D. In one large 
royal 12mo. volume, of about 850 pp., cloth, $2*75 ; leather, $3 25. (Lately Iss?ted.) 



This work is so well known that it seems almost 
superfluous for us to speak about it. It has been a 
favorite text-book with medical students for years, 
and its popularity has in no respect diminished. 
Whenever we have been consulted by medical stu- 
dents, as has frequently occurred, what treatise on 
chemistry they should procure, we have always re- 
commended Fownes', for we regarded it as the best. 
There is no work that combines so many excellen- 



■>ther work that has greater claims on the physician, 
pharmaceutist, or student, than this. We cheerfully 
recommend it as the best text-book on elementary 
chemistry, and bespeak for it the careful attention 
of students of pharmacy. — Chicago Pharmacist, Aug, 
1869. 

Here is a new edition which has been long watched 
for by eager teachers of chemistry. In its new garb, 



ces. It is of convenient size, not prolix, of plain and under the editorship of Sir. Watts, it has resumed 
perspicoous diction, contains all the most recent its old place as the most successful of text-books.— 



discoveries, and is of moderate price 
Med. Repertory, Aug. 1869. 



-Cincinnati I Indian Medical Gazette, Jau. 1, 1869 



It will continue, as heretofore, to hold the first rani 
Large additions have been made, especially in the is a text-book for students of medicine. — Chicago 
department of organic chemistry, and we know of no Y?d. Examiner, Aug. 1S69. 







DLING ( WILLIAM), 

Lecturer on Chemistry at St. Bartholomew's Hospital, &c. 

A COURSE OF PRACTICAL CHEMISTRY, arranged for the Use 

of Medical Students. With Illustrations. From the Fourth and Bevised London Edition. 
In one neat royal 12mo. volume, cloth, $2. 



flALLOWAY {ROBERT), F.G.S., 

*^" Prof, of Applied Chemistry in the Royal College of Science for Ireland, <ftc. 

A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lob- 

don Edition. In one neat royal 12mo. volume, with illustrations; cloth, $2 50. (Just 
Issued.) 

The success which has carried this work through repeated editions in England, and it3 adoption 
as a text-book in several of the leading institutions in this country, show that the author has suc- 
ceeded in the endeavor to produce a sound praotieal manual and book of reference for the che- 
mical student. 

Prof Galloway's books are deservedly in high i We regard this volume as a valuable addition to 
esteem, and this American reprint of the fifth edition \ the chemical text-books, and as particularly calca- 
(1869) of his Manual of Qualitative Analysis, will be I lated to instruct the student in analytical researches 
acceptable to many American students to whom the \ of the inorganic compounds, the important vegetable 
English edition is not accessible. — Am, Jour, of Set- I acids, and of compounds and various secretions asd 
ince and Arts, Sept. 1872. excretions of animal origin, —Am. Jo-am. of Pharm,., 

I Sapt, 1S72. 



Henry C. Lea's Publications— {Chemistry). 



11 



'jDLOXAM {G. L.), 

•*-* Professor of Chemistry in King's College, London. 

CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- 

don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illustra- 
tions. Cloth, $4 00; leather, $5 00. (Lately Issued.) 
It has been the author's endeavor to produce a Treatise on Chemistry sufficiently comprehen- 
sive for those studying the science as a branch of general education, and one which a student 
may use with advantage in pursuing his chemical studies atone of the colleges or medical schools. 
The special attention devoted to Metallurgy and some other branches of Applied Chemistry renders 
the work especially useful to those who are being educated for employment in manufacture. 



We have in this work a complete and most excel- 
lent text-book for the use of schools, and can heart- 
ily recommend it as such. — Boston Med. and Surg. 
Journ., May 23, 1874. 

Of all the numerous works upon elementary chem- 
istry that have been published within the last few 
years, we can point to none that, in fulness, accuracy, 
and simplicity, can surpass this; while, in the num- 
ber and detailed descriptions of experiments, as also 
in the profuseness of its illustrations, we believe it 
stands above any similar work published in this coun- 
try The statements made are clear and con- 
cise, and every step proved by an abundance of ex- 
periments, which excite our admiration as much by 
their simplicity as by their direct conclusiveness. — 
Chicago Med. Examiner, Nov. 15, 1873. 

It is seldom that in the same compass so complete 
and interesting a compendium of the leading facts of 
chemistry is offered.— Druggists' Circular, Nov. '73. 
The above is the title of a work which we can most 
conscientiously recommend to students of chemistry. 
It is as easy as a work on chemistry could be made, 
at the same time that it presents a full account of that 
science as it now stands. We have spoken of the 
work as admirably adapted to the wants of students ; 
it is quite as well suited to the requirements of prac- 
titioners who wish to review their chemistry, or have 
occasion to refresh their memories on any point re- 
lating to it. In a word, it is a book to be read by all 
who wish to know what is the chemistry of the pre- 
sent day. — American Practitioner, Nov. 1873. 

Among the various works upon general chemistry 
issued, we know of none that will supply the average 
wants of the student or teacher better than this. — 
Indiana Journ. of Med., Nov. 1873. 

We cordially welcome this American reprint of a 
work which has already won for itself so substantial 
a reputation in England. Professor Bloxam has con- 
densed into a wonderfully small compass all the im- 
portant principles and facts of chemical science. 
Thoroughly imbued with an enthusiastic love for the 
science he expounds, he has stripped it of all need- 
less technicalities, and rounded out its hard outlines 
by a fulness of illustration that cannot fail to attract 
and delight the student. The details of illustrative 



experiment have been worked up with especial care, 
and many of the experiments described are both new 
and striking. — Detroit Rev. of Med. and Pharm., 
Nov. 1873. 

One of the best text-books of chemistry yet pub- 
lished. — Chicago Med. Journ., Nov. 1873. 

This is an excellent work, well adapted for the be- 
ginner and the advanced student of chemistry. — Am. 
Journ. of Pharm., Nov. 1873. 

Probably the most valuable, and at the same time 
practical, text-book on general chemistry extant in 
our language. — Kansas City Med. Journ., Dec. 1873. 

Prof. Bloxam possesses pre-eminently the inestima- 
ble gift of perspicuity. It is a pleasure to read his 
books, for he is capable of makiug very plain what 
other authors frequently have left very obscure. — 
Va. Clinical Record, Nov. 1S73. 

It would be difficult for a practical chemist and 
teacher to find any material fault with this most ad- 
mirable treatise. The author has given us almost a 
cyclopedia within the limits of aconrenient volume, 
and has done so without penning the useless para- 
graphs too commonly making up a great part of the 
bulk of many cumbrous works. The progressive sci- 
entist is not disappointed when he looks for the record 
of new and valuable processes and discoveries, while 
the cautious conservative does not find its pages mo- 
nopolized by uncertain theories and speculations. A 
peculiar point of excellence is the crystallized form of 
expression in which great truths are expressed in 
very short paragraphs. One is surprised at the brief 
space allotted to an- important topic, and yet, after 
reading it, he feels that little, if any more, should 
have been said. Altogether, it is seldom you see a 
text-book so nearly faultless.— Cincinnati Lancet 
Nov. 1873. 

Professor Bloxam has given us a most excellent 
and useful practical treatise. His 666 pages are 
crowded with facts aud experiments, nearly all well 
chosen, and many quite new, even to scientific men. 
. . . It is astonishing how much information he often 
conveys in a few paragraphs. We might quote fifty 
instances of this. — Chemical News. 



WOHLER AND FITTIG. 

¥V OUTLINES OF ORGANIC CHEMISTRY. Translated with Ad- 
ditions from the Eighth German Edition. By Ira Remsen, M.D., Ph.D., Professor of 
Chemistry and Physics in Williams College, Mass. In one handsome volume, royal 12mo. 
of 550 pp., cloth, $3. 
As the numerous editions of the original attest, this work is the leading text-book and standard 
authority throughout Germany on its important and intricate subject — a position won for it by 
the clearness and conciseness which are its distinguishing characteristics. The translation has 
been executed with the approbation of Profs. Wbhler and Fittig, and numerous additions and 
alterations have been introduced, so as to render it in every respect on a level with the most 
advanced condition of the science. 

J£0 WMAN {JOHN E.) ,M.D. 

PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited 

by C.^L. Bloxam, Professor of Practical Chemistry in King's College, London. Sixth 
American, from the fourth and revised English Edition. In one neat volume, royal 12mo., 
pp. 351, with numerous illustrations, cloth, $2 25. 
J£Y THE SAME AUTHOR. (Lately Issued.) 

INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING 

ANALYSIS. Sixth American, from the sixth and revised London edition. With numei- 
oas illustrations. In one neat vol., royal 12mo., cloth, $2 25. 



KH" APP'S TECHNOLOGY ; or Chemistry Applied to 
the Arts, and to Manufactures. With American 
fcdditioas, by Prof. Wastes. S. Johkson. In two 



very handsome octavo vol an?.es, with 500 wood 
engravings, oloth, $8 00 



12 Henry 0. Lba ? s Publications— (Mat. Med. and Therapeutics). 
pARRISH {EDWARD), 

Late Professor of Materia Medica. in the Philadelphia College of Pharmacy . 

A TREATISE ON PHARMACY. Designed as a Text-Book for the 

Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and 
Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wiegand. In on® 
handsome octavo volume of 977 pages, with 280 illustrations; cloth, %b 50; leather, $6 50. 
{Lately Issued.) 
The delay in the appearance of the new U. S. Pharmacopoeia, and the sudden death of the au- 
thor, have postponed the preparation of this new edition beyond the period expected. The notes 
and memoranda left by Mr. Parrish have been placed in the hands of the editor, Mr. Wiegand, 
who has labored assiduously to embody in the work all the improvements of pharmaceutical sci- 
ence which have been introduced during he last ten years. It is therefore hoped that the new 
edition will fully maintain the reputation which the volume has heretofore enjoyed as a standard 
text-book and work of reference for all engaged in the preparation and dispensing of medicines. 

Of Dr. Parrish's great work on pharmacy it only- 
remains to be said that the editor has accomplished 
his work so well as to maintain, in this fourth edi- 
tion, the high standard of excellence which it had 
attained in previous editions, under the editorship of 
its accomplished author. This has not been accom- 
plished without much labor, and many additions and 
improvements, involving changes in the arrangement 
of the several parts of the work, and the addition of 
much new matter. With the modificatious thus ef- 
fected it constitutes, as now presented, a compendium 
of the science and art indispensable to the pharma- 
cist, and of the utmost value to every practitioner 
of medicine desirous of familiarizing himself with 
the pharmaceutical preparation of the articles which 
he prescribes for his patients. — Chicago Med. Journ., 
July, 1S74. 

The work is eminently practical, and has the rare 
merit of being readable and interesting, while it pre- 
serves a stricily scientific character. The whole work 
reflects the greatest credit on author, editor, and pub- 
lisher It will convey some idea of the liberality which 
has been bestowed upon its production when we men- 
tion that there are no less than 2S0 carefully executed 
illustrations. In conclusion, we heartily recommend 
the work, not only to pharmacists, but also to the 
multitude of medical practitioners who are obliged 
to compound their own medicines. It will ever hold 



an honored place on our own bookshelves. — Dublin 
Med. Press and Circular, Aug. 12, 1874. 

We expressed our opinion of a former edition in 
terms of unqualified praise, and we are in no mood 
to detract from that opinion in reference to the pre- 
sent edition, the preparation of which has fallen into 
competent hands. It is a book with which no pharma- 
cist can dispense, and from which no physician can 
fail to derive much information of value to him in 
practice. — Pacific Med. and Surg. Journ., June, '74. 

With these few remarks we heartily commend the 
work, and have no doubt that it will maintain its 
old reputation as a text-book for the student, and a 
work of reference for the more experienced physi- 
cian and pharmacist . — Chicago Med. Examiner, 
June 15, 1874. 

Perhaps one, if not the most important book upon 
pharmacy which has appeared in the English lan- 
guage has emanated from the transatlantic press. 
" Parrish 's Pharmacy" is a well-known work on this 
side of the water, and the fact shows us that a really 
useful work never becomes merely local in its fame. 
Thanks to the judicious editing of Mr. Wiegand, the 
posthumous edition of "Parrish" has been saved to 
the public with all the mature experience of its au- 
thor, and perhaps none the worse for a dash of new 
blood. — Land. Pharm. Journal, Oct. 17, 1874. 



OTILLE {ALFRED), M.D., 

*3 Professor of Theory and Practice of Medicine in the University of Penno.. 

THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise 

on the Action and Uses of Medicinal Agents, including their Description and Historj. 

Fourth edition, revised and enlarged. In two large and handsome 8vo. vols, of about 2000 

pages. Cloth, $10; leather, $12. {Just Iss?ied.) 
The care bestowed by the author on the revision of this edition has kept the work out of the 
market for nearly two years, and has increased its size about two hundred and fifty pages. Not- 
withstanding this enlargement, the price has been kept at the former very moderate rate. 



It is unnecessary to do much more than to an- 
nounce the appearance of the fourth edition of this 
well known and excellent work. — Brit, and For. 
Med.-Chir. Review, Oct. 1875. 

For all who desire a complete work on therapeutics 
and materia medica for reference, in cases involving 
medico-legal questions, as well as for information 
concerning remedial agents, Dr. Stille's is '■'■par ex- j 
cellence" the work. The work being out of print, by 
the exhaustion of former editions, the author has laid I 



the profession under renewed obligations, by the 
careful revision, important additions, and timely re- 
issuing a work not exactly supplemented by any 
other in the English language, if in any language. 
The mechanical execution handsomely sustains the 
well-known skill and good taste of the publisher. — 
St. Louis Med. and Surg.- Journal, Dec. 1874. 

The prominent feature of Dr. Stille s great work 
is sound good sense. It is learned, but its learning 
is of inferior value compared with the discriminating 
judgment which is shown by its author in the dis- 
cussion of his subjects, and which renders it a trust- 
worthy guide in the sick-room. — Am. Practitioner, 
Jan. 1875. 

From the publication of the first edition " Stille's 
Therapeutics" has been one of the classics; its ab- 
sence from our libraries would create a vacuum 
which could be filled by no other work in the lan- 



guage, and its presence supplies, in the two volumes ' 1874. 



of the present edition, a whole cyclopaedia of thera- 
peutics. — Chicago Medical Journal, T?el). 1875. 

The magnificent work of Professor Stifle is known 
wherever the English language is read, and the art 
of medicine cultivated ; known so well that no enco- 
mium of ours could brighten its fame, and no unfa- 
vorable criticism could tarnish its reputation.— Phil- 
adelphia Med. Times, Dec. 12, 1S74, 

The rapid exhaustion of three editions and the uni- 
versal favor with which the work has been received 
by the medical profession, are sufficient proof of its 
excellence as a repertory of practical and useful in- 
formation for the physician. The edition before us 
fully sustains this verdict, as the work has been care- 
fully revised and in some portions rewritten, bring- 
ing it up to the present time by the admission of 
chloral and croton-chloral, nitrite of amyl, bichlo- 
ride of methylene, methylic ether, lithium com- 
pounds, gelseminum, and other remedies. — Am. 
Journ. of Pharmacy, Feb. 1875. 

We can hardly admit that it has a rival in the 
multitude of its citations and the fulness of its re- 
search into clinical histories, and we must assign it 
a place in the physician's library; not, indeed, as 
fully representing the present state of knowledge in 
pharmacodynamics, but as by far the most complete 
treatise upon the clinical and practical side of the 
question. — Boston Mtd. and. Surg. Journal, Kov.5» 



Henry C. Lea's Publications— {Mat. Med. and Therapeutics). 13 



Q.RIFFITH (ROBERT E.), M.D. 

A UNIVERSAL FORMULARY, Containing the Methods of Prepar- 
ing and Administering Officinal and other Medicines. The whole adapted to Physician? and 
Pharmaceutists. Third edition, thoroughly revised, with numerous additions, tn John M. 
Maisgh, Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large 
and handsome octavo volume of about 800 pages, cloth, $4 50 ; leather, $5 50. (Just Issited ) 

This work has long been known for the vast amount of information which it presents in a con- 
densed form, arranged for easy reference. The new edition has received the most careful revi- 
sion at the competent hands of Professor Maisch, who has brought the whole up to the standard of 
fche most recent authorities. More than eighty new headings of remedies have been introduced, 
the entire work has been thoroughly remodelled, and whatever has seemed to be obsolete has been 
omitted. As a comparative view of the United States, the British, the German, and the French 
Pharmacopoeias, together with an immense amount of unofficinal formulas, it affords to the prac- 
titioner and pharmaceutist an aid in their daily avocations not to be found elsewhere, while three 
indexes, one of "Diseases and their Remedies," one of Pharmaceutical Names, and a General 
Index, afford an easy key to the alphabetical arrangement adopted in the text. 

The young practitioner will find the work invalu- j 
% eligible modes of administering i 
Am. Joury,. of Pkarm., Feb. 1874. 

Our copy of Griffith's Formulary, after long use, 1 
first in the dispensing shop, and afterwards in our J 
medical practice, had gradually fallen behind in the I 
onward march of materia medica, pharmacy, and 
therapeutics, until we had ceased to consult it as a I 
daily book of reference. So completely has Prof. 
Maisch reformed, remodelled, and rejuvenated it in 
the new edition, we shall gladly welcome it back fco 
ourtable again beside Dunglison, Webster, and Wood 
& Backe. The publisher could not have been more 
fortunate in the selection of an editor. Prof. Maisch 
is eminently the. man for the woi-k, and he has done 
it thoroughly and ably. To enumerate the altera- 
tions, amendments, and additions would be an end- 
Less task; everywhere we are greeted with the evi- 
dences of his labor. Following the Formulary, is an 
addendum of useful Recipes, Dietetic Preparations, 
List of Incompp.tibles, Posological table, table of 
Pharmaceutical Names, Officinal Preparations and 
Directions, Poisons, Antidotes, and Treatment, and 
copious indices, which afford ready access to all parts 
of the work. We unhesitatingly commend the book 
as being the best of its kind, within our knowledge. 
— Atlanta Med. and Stcrg. Journ,^ Feb. 1874, 



able in suggest 
many remedies. 



To the druggist a good formulary is simply indis- 
pensable, and perhaps no formulary has been mire 
extensively used than the well-known work before 
us. Many physiciaus have to officiate, also, as drug- 
gists This is true especially of the country physi- 
cian, and a work which shall teach him the means 
by which to administer or combine his remedies in 
the most efficacious and pleasant manner, will al- 
ways hold its place upon his shelf. A formulary of 
this kind is of benefit also to the city physician in 
largest practice.— Cincinnati llinic, Feb. 21, 187-t. 

The Formulary has already proved itself accepta- 
ble to the medical profession, and we do not hesitate 
to say that the third edition is much improved, and 
of greater practical value, in consequence of the care- 
ful revision of Prof Maisch.— Chicago* Med. Exam- 
iner, March 15, 1874. 

A more complete formulary than it is in its pres- 
ent form the pharmacist or physician could hardly 
desire. To the first some such work is indispensa- 
ble, and it is hardly less essential to the practitioner 
who compounds his own medicines. Much of what 
is coutained in the introduction ought to be com- 
mitted to memory by every student of medicine. 
As a help to physieians it will be found invaluable, 
and doubtless will make its way into libraries not 
already supplied with a standard work of the kind. 
— The American Practitioner, Louisville, July, '7-L 



fJLLIS {BENJAMIN), M.D. 

THE MEDICAL FORMULARY: being a Collection of Prescriptions 

derived from the writings and practice of many of the most eminent physicians of America 
and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. The 
whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- 
tion, carefully revised and much improved by Albert H. Smith, M. 2X la one volume 8v@. 
of 376 pages, cloth, $3 00. 



13EREIRA [JONATHAN), M.D., F.R.S. and L.S. 
X MATERIA MEDICA AND THERAPEUTICS; being an Abridg- 

ment of the late Dr. Pereira's Elements of Materia Medica, arranged in conformity with 
the British Pharmacopoeia, and adapted to the use of Medical Practitioners, Chemists and 
Druggists, Medical and Pharmaceutical Students, <fec. By F. J. Farrk, M.D., Senior 
Physician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia ; 
assisted by Robert Bbktlev, M.R.C.S., Professor of Materia Medica and Botany to the 
Pharmaceutical Society of Great Britain; and by Robert Warington, F.R.S. , Chemical 
Operator to the Society of Apothecaries. With numerous additions and references to the 
United States Pharmacopoeia, by Horatio C. Wood, M.D., Professor of Botany in the 
University of Pennsylvania. In one large and handsome octavo volume of 1040 closely 
printed pages, with 236 illustrations, cloth, $7 00; leather, raised bands, $8 00. 



D HNGLISON'S NEW REMEDIES, WITH FORMULA 
FOR THEIR PREPARATION AND ADMINISTRA- 
TION. Seventh edition, with extensive additions. 
One vol. 8vo., pp. 770; cloth. $4 00. 

WHAT TO GBSERVE AT THE BEDSIDE AND AFTEE 
Death is Medical Cases. Published under the 
authority of the London Society for Medical Obser- 
ration. From the second London edition. 1 vol. 
royal 12mo,, cloth. $1 00. 



I '•HRIoTISON'S DISPENSATORY. With copious ad 
-H.ir.TiB, and 213 large wood-GnKra^nsrs By R 
Eglesfeld Griffith, M.D. One vol. 8vo., pp. 1000 

i cloth. $4 00. 

j CARPENTER'S PRIZE ESSAY ON THE USE OF 
Alcoholic Liquors in Health and Disease. New 
edition, with a Preface by D. F. Condie, M.D., and 
explanations of scientific words. In one neat 12mo. 

1 volume, pp. 178, cloth. 60 cents. 



14 



Henry C. Lea's Publications— (Pathology, &c). 



J>RUNTON (T. LAUDER), 31. D., 

-&-* Lecturer on Materia Medica and Therapeutics at St. Bartholorntw's Hospital, &c. 

A MANUAL OF MATERIA MEDICA AND THERAPEUTICS. 

INCLUDING THE PHARMACY, THE PHYSIOLOGICAL ACTION, AND THE THE- 
RAPEUTICAL USES OF DRUGS. In one neat octavo volume. {Preparing.) 



JPENW1CK {SAMUEL), M.D,, 

■*- Assistant Physician to the London Hospital. 

THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the 

Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. 
In one very handsome volume, royal 12mo., cloth, $2 25. (Jnst Iss7ied.) 



Of the many guide-books on medical diagnosis, 
claimed to be written for the special instruction of 
students, this is the best. The author is evidently a 
well-read and accomplished physician, and he knows 
how to * each practical medicine. The charm of sim- 
plicity is not the least interestiugfeatnrein the man- 
ner in which Dr. Fenwick conveys instruction. There 
are few books of this size on practical medicine that 
contain so much and convey it so well as the volume 
before us. It is a book we can sincerely recommend 
to the student for direct instruction, and to the prac- 
titioner as a ready and useful aid to his memory.— 
Am. Journ. of Syphilography, Jan. 1874. 

It covers the ground of medical diagnosis in a con- 



cise, practical manner, well calculated to assist the 
student in forming a correct, thorough, and system- 
atic method oi f examination and diagnosis of disease. 
The illustrations are numerous, and finely executed. 
Those illustrative of the microscopic appearance of 
morbid tissue, &c, are especially clear and distinct. 
— Chicago Med. Examiner, Nov. 2673. 

So far superior to any offered to students that the 
colleges of this country should recommend it to their 
respective classes. — y. O. Med. and Surg. Journ., 
March, 1874. 

This little book ought to be in the possession ol 
every medical student. — Boston Medical and Surg. 
Journ., Jan. 15, 1S74. 



o 



RE EN (T. HENRY), M.D., 

Lecturer on Pathology and Morbid Anatomy at Charing-Oross Hospital Medical School. 

PATHOLOGY AND MORBID ANATOMY. With numerous Illus- 
trations on Wood. In one very handsome octavo volume of over 250 pages, cloth, $2 50. 
{Lately Published.) 

thology and morbid anatomy. The author shows that 
he has been not only a student of the teachings of his 
confreres in this branch of science, but a practical 
and conscientious laborer in the post-mortem cham- 
ber. The work will provea useful one to the great 
mass of students and practitioners whose time for de- 
votion to this class of studies is limited.— Am. Journ. 
of Syphilography, April, 3872. 



We have been very much pleased by our perusal of 
this little volume. It is the only one of the kind with 
which we are acquainted, and practitioners as well 
as students will find it a very useful guide ; for the 
information is up to the day, well and compactly ar- 
ranged, without being at all scanty.— London Lmn- 
eet, Oct. 7, 1871. 

It embodies in a comparatively small space a clear 
statement of the present state of our knowledge of pa- 



GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. 
Translated, with Notes and Additions, by Joseph 
Leidy, M. D. In one volume, very large imperial 
quarto, with 320 copper-plate figures, plain and 
colored, cloth. $4 00. 

LA ROCHE ON YELLOW FEVER, considered in its 
Historical, Pathological, Etiological, and Therapeu- 
tical Relations. In two large and handsome octavi 
volumes of nearly 1500 pages, cloth. $7 00. 

HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. 8vo., pp. 500, cloth. $3 60. 



LAYCOCK'S LECTURES ON THE PRINCIPLES 
and Methods of Medical Observation and Re- 
search. For the use of advanced students and 
j unior practitioners. In one 'very ueat royal 12mc . 
volume, cloth. $1 00. 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With Additions by D. F. Cosdib, 
M D. 1 vol. 8vo., pp. 600, cloth. $2 50. 

TODD'S CLINICAL LECTURES ON CERTAIN ACUTE 
Diseases. In one neat octavo volume, of 320 pagea, 
cloth. $2 60. 



S 



TURGES {OGTAVIUS), M.D. Cantab., 

Fellow of the Royal College of Physicians, &-c. <fre. 

AN INTRODUCTION TO THE STUDY OP CLINICAL MED- 
ICINE. Being a Guide to the Investigation of Disease, for the Use of Students. Id one 
handsome 12mo. volume, cloth, $1 25. {Litely Issued.) 



T)AYIS [NATHAN S.), 

-U Prof, of Principles and Practice of Medicine, etc., in Chicago Med. College. 

CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES ; 

being a collection of the Clinical Lectures delivered in the Medical Wards of Mercy Hos- 
pital, Chicago. Edited by Frank H. Davis, M.D. Second edition, enlarged. In one 
handsome royal 12mo. volume. Cloth, $1 75. {Lately Issued.) 



VTOKES (WILLIAM), M.D., D.C.L., F.R.S., 

*-J Regius Professor of Physic in the Univ. of I>xiblin, See. 

LECTURES ON FEVER, delivered in the Theatre of the Meath Hos- 
pital and County of Dublin Infirmary. Edited by John William Moore, M.D , Assistant 
Physician to the Cork Street Fever Hospital. In one neat octavo volume. {Preparing.) 
#*^ To appear in the •' Medical News and Library" for 1875. 



Henry C. Lea's Publications— {Practice of Medicine). 



15 



IjfLINT {AUSTIN), M.D., 

«». Professor of the Principles and Practice of Medicine in Belleuue Med. College, N. Y. 

A TREATISE ON THE PRINCIPLES AND PRACTICE OF 

MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth 

edition, revised and enlarged. In one large and closely printed octavo volume of about 1100 

pages ; cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. {Just Issued.) 

By common consent of the English and American medical press, this work has been assigned 

6o the highest position as a complete and compendious text-book on the most advanced condition 

of medical science. At the very moderate price at which it is offered it will be found one of the 

cheapest volumes now before the profession. A few notices of previous editions are subjoined. 



Western Journal of 



Admirable and unequalled 
Medicine, Nov. 1869. 

Dr. Flint's work, though, claiming no higher title 
than that of a text-book, is really more. He is a man 
of large clinical experience, and his book is full of 
«uch masterly descriptions of disease as can only be 



excellently printed and bound — and we encounter 
that luxury of America, the ready-cut pages, which 
the Yankees are 'cute enough- to insist upon — nor are 
these by any means trifles ; but the contents of the 
book are astonishing. Not only is it wonderful that 
any one man can have grasped in his mind the whole 



drawn by a man intimately acquainted with their j scope of medicine with that vigor which Dr. Flint 
various forms. It is not so long since we had the j 3hows, but the condensed yet clear way in which 
pleasure of reviewing his first edition, and we recog- j tn i g is done is a perfect literary triumph. Dr. Flint 
aize a great improvement, especially in the general 1 * s pre-eminently one of the strong men, whose right 
part of the work. It is a work which we can cordially ] to do this kind of thing is well admitted ; and we say 
recommend to our readers as fully abreast of the sci- j no more than the truth when we affirm that he is 
sa.ce of the day. — Edinburgh Med. Journal, Oct. '69. j very nearly the only living man that could do it with 

One of the best works of the kind for the practi- i such results as the volume before vs.— The London 
fcioner, and the most convenient of ail for the student. Practitioner, March, 1869 
«~Am. Journ. Med. Sciences, Jan. 1869. 

This work, which stands pre-eminently as the ad- 
vance standard of medical science up to the present 
&ime in the practice of medicine, has for its author 
one who is well and widely known as one of the 
leading practitioners of this continent. In fact, it is 
seldom that any work is ever issued from the press 
more deserving of universal recommendation. — Bo- 
minion Med. Journal, May, 1869. 

The third edition of this most excellent book scarce- 
ly needs any commendation from us. The volume, 
&s it stands now, is really a marvel : first of all, it is 



This is in some respects the best text-book of medi- 
cine in our language, and it is highly appreciated on 
the other side of the Atlantic, inasmuch as the first 
8dition was exhausted in a few months. The second 
sdition was little more than a reprint, but the present 
has, as the author says, been thoroughly revised. 
Much valuable matter has been added, and by mak- 
ing the type smaller, the bulk of the volume is not 
much increased. The weak point in many American 
works is pathology, but Dr. Flint has taken peculiar 
pains on this point, greatly to the value of the book, 
—London Med. Times and Gazette, Feb. 6, 1869. 



£>F THE SAME AUTHOR. 

ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED 

TOPICS. In one very handsome royal 12mo. volume. Cloth, $1 38. {Just Issued.') 

CONTENTS. 
I. Conservative Medicine.- II. Conservative Medicine as applied to Therapeutics. III. Con- 
servative Medicine as applied to Hygiene. IV. Medicine in the Past, the Present, and the Fu- 
ture. V. Alimentation in Disease. VI. Tolerance of Disease. VII. On the Agency of the 
Mind in EtiolGgy, Prophylaxis, and Therapeutics. VIII. Divine design as exemplified in th© 
Natural History of Disease. 

TXTATSON {THOMAS), M. D., frc. 

LECTURES ON THE PRINCIPLES AND PRACTICE OF 

PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- 
vised and enlarged English edition. Edited, with additions, and several hundred illustra- 
ations, by Henry Hartshgrne, M.D., Professor of Hygiene in the University of Pennsylv- 
nia. In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. {Lately Published.) 

rare combination of great scientific attainments com- 
bined with wonderful forensic eloquence has exerted 



It is a subject for congratulation and for thankful- 
ness that Sir Thomas Watson, during a period of com- 
parative leisure, after a long, laborious, and most 
honorable professional career, while retaining full 
possession of his high mental faculties, should have 
employed the opportunity to submit his Lectures to 
a more thorough revision than was possible during 
the earlier and busier period of his life. Carefully 
passing in review some of the most intricate and im- 
portant pathological and practical questions, there- 
suits of his clear insight and his calm judgment are 
now recorded for the benefit of mankind, in language 
which, for precision, vigor, aud classical elegance, has 
rarely been equalled, and never surpassed The re- 
vision has evidently been caost earefully done, and 
the results appear in almost every page. — Brit. Med. 
Journ., Oct. 14, 1871. • 

The lectures are so well known and so justly 
appreciated, that it is scarcely necessary to do 
more than call attention to the special advantages 
of the last over previous editions. The author's 



extraordinary influence over the last two generations 
of physicians. His clinical descriptions of most dis- 
eases have never been equalled ; and on this score 
at least his work will live long in the future. The 
work will be sought by all who appreciate a great 
book. — Araer. Journ. of Syphilography, July, 1872. 
We are exceedingly gratified at the reception of 
this new edition of Watson, pre-eminently the prince 
of English authors, on "Practice." We, who read 
the first edition shall never forget the great pleasure 
and profit we derived from its graphic delineations 
of disease, its vigorous style and splendid English. 
Maturity of years, extensive observation, profound 
research, and. yet continuous enthusiasm, have com- 
bined to give us in this latest edition a model of pro- 
fessional excellence in teaching with rare beauty in 
the mode of communication. But this classic needs 
no eulogium of ours.— Chicago Med. Journ., July, 
1872. 



ryUNGLISON, FORBES, TWEEDIE, AND CONOLLY. 
^THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising 

Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics, 
Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super-royal 
octavo volumes, of 3254 double-columned pages, strongly and handsomely bound in leather, 
$15; cloth, $1.1. 



16 



Hbney C. Lea's Publications — (Practice of Medicine), 



ffARTSHORNE {HENRY), M.D., 

■"■J. Professor of Hygiene in the University of Pennsylvania. 

ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MED1- 

CINE. A handy-book for Students and Practitioners. Fourth edition, revised and im- 
proved. With about one hundred illustrations. In one handsome royal 32nio. volame, 
of about 550 pages, cloth, $2 63 ; half bound, $2 88. (Just Issued.) 
The thorough manner in which the author has labored to fully represent in this favorite hand- 
book the most advanced condition of practical medicine is shown by the fact that the pregent 
edition contains more thnn 250 additions, representing the investigations of 172 authors not re- 
ferred to in previous editions. Notwithstanding an enlargement of the page, the size has been 
increased by sixty pages. A number of illustrations have been introduced which it is hoped 
will facilitate the comprehension of details by the reader, and no effort has been spared to make 
the volume worthy a continuance of the very great favor with which it has hitherto been received. 



The work is brought fully up with all the recent 
advances in medicine, is admirably condensed, and 
yet sufficiently explicit for all the purposes intended, 
thus making it by far the best work of its character 
ever published.— Cincinnati Clinic, Oct. 24, 1874. 

We have already had occasion to notice the previ- 
ous editionsof thiswork. It is excellent of its kind. 
The author has given a very careful revision, in view 
of the rapid progress of medical seience.— N. Y. Med. 
Journ., Nov. 1874. 



Without doubt the best book of the kind published 
in the English language. — St. Louis Med. and Surg, 
Journ., Nov. 1874. 

As a handbook, which clearly sets forth the essen- 
tials Of the PRINCIPLES AND PRACTICE OP MEDICINE, W8 

do not know of its equal.— Va. Med. Monthly. 

As a brief, condensed, but comprehensive hand- 
book, it cannot be improved upon. — Chicago Med. 
Examiner, Nov. 35, 1874. 



pAVY{F. W.),M.D.,F.R.S. t 

■M- Senior Asst. Physician to and Lecturer on Physiology, at €her/s Hospital, &n. 

A TREATISE ON THE FUNCTION OF DIGESTION; its Disor- 

ders and their Treatment. From the second London edition. In one handsome volum*, 
small octavo, cloth, $2 00. 
jyY THE SAME AUTHOR. (Just /«*««?.) 

A TREATISE ON FOOD AND DIETETICS, PHYSIOLOGI- 
CALLY AND THERAPEUTICALLY CONSIDERED. In one handsome octavo volume 
of nearly 600 pages, cloth, $4 75. 

SUMMARY OF CONTENTS. 

Introductory Remarks on the Dynamic Relations of Food — On the Origination of Food — The 
Constituent Relations of Food — Alimentary Principles, their Classification, Chemical Relati ons. 
Digestion, Assimilation, and Physiological Use3 — Nitrogenous Alimentary Principles — Non- Ni- 
trogenous Alimentary Principles — The Carbo-Hydrates — The Inorganic Alimentary Principles — 
Alimentary Substances — Animal Alimentary Substances — Vegetable Alimentary Substances — 
Beverages — Condiments — The Preservation of Food — Principles of Dietetics — Practical Dietetics 
— Diet of Infants — Diet for Training — Therapeutic Dietetics — Dietetic Preparations for the Inva- 
lid — Hospital Dietaries. 

ftHAMBERS {T. K.), M.D., ~~~ 

^J Consulting Physician to St. Mary's Hospital, London, &e. 

A MANUAL OF DIET AND REGIMEN IN HEALTH AND SICK- 

NESS. In one handsome octavo volume. Cloth, $2 75. (Now Ready.) 

convey his meaning in the fewest possible words, he 
is certainly unexcelled and rarely equalled by any 
writer ia the English language. It is altogether a 
work of rare excellence, and should, as it doubtless* 
will, speedily find a place on the table of ©very phy- 
sician. — TheN. Y. Sanitarian, June, 1S75. 

Thiswork is a substantial addition to our standard 
works, and not only should the neat little volume 
find a place in tbe most restricted libraries, bat its 
contents ought to be read, marked, learned, and in- 
wardly digested by each practitioner, mntil they 
have become woven into the web of the ordinary 
©very-day thought of all medical men who traly love 
their profession. — Land. Praiiitioner, June, 183&. 



In compiling this small but comprehensive manual 
Dr. Chambers has laid the profession under a debt 
of gratitude to him. Rewrites on the subject like 
one who has given his mind to it, and therefore is 
entitled to speak with authority. As a pioneer, Dr. 
Chambers deserves much credit ; he has opened up a 
new field of which others will no doubt avail them- 
selves. Taken altogether, this work is one which 
gives, in an agreeable form, much valuable informa- 
tion on a most important subject, and ought to have 
a large sale both in the profession and out of it. — 
London Med. Record, May 19, 1875. ' 

In thorough mastery of the subjects uponwhieb. he 
writes, and in the happy command of language to 



J>Y THE SAME AUTHOR. (Lately Published.) 

RESTORATIVE MEDICINE. An Harveian Annual Oration. 

Two Sequels. In one very handsome volume, small 12mo., cloth, $1 00. 



With 



-nRINTON {WILLIAM), M.D., F.R.S. 
^LECTURES ON THE DISEASES OF THE STOMACH; with an 

Introduction on its Anatomy and Physiology. From the second and enlarged London edi- 
tion. With illustrations on wood In one handsome octavo volume of about 300 pages 

oloth, $3 25. „____ 

POX { WILSON), M.D., 

-*■ Holme Prof, of Clinical Med., University Coll., London. 

THE DISEASES OF THE STOMACH: Being the Third Edition of 

the "Diagnosis and Treatment of the Varieties of Dyspepsia " Revised and Enlarged. 
With illustrations. In one handsome octaYo yoUime 3 cloth s $2 00, (Just Issued*) 



Henry C. Lea's Publications. 



17 



J^LINT [AUSTIN), M.D., 

-*■ Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. Y. 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 

AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 
edition. In one octavo volume of 550 pages, with a plate, cloth, $4. 



Dr. Flint chose a difficult subject for his researches, 
and has shown remarkable powers of observation 
and reflection, as well as great industry, in his treat- 
ment of it. His book must be considered the fullest 
and clearest practical treatise on those subjects, and 
should be in the hands of all practitioners and stu- 
dents. It is a credit to American medical literature. 
— Amer. Journ. of the Med. Sciences, July, 1860. 

We question the fact of any recent American author 
In our profession being more extensively known, or 
more deservedly esteemed in this country than Dr. 
Flint. We willingly acknowledge his success, more 
particularly in the volume on diseases of the heart, 
in making an extended personal clinical study avail- 



able for purposes of illustration, in connection with 
cases which have been reported by other trustworthy 
observers. — Brit, and For. Med.-Chirttrg. Review. 

In regard to the merits of the work, we have no 
hesitation in pronouncing it full, accurate, and judi- 
cious. Considering the present state of science, such 
a work was much needed. It should be in the hands 
of every practitioner. — Chicago Med. Journ. 

With more than pleasure do we hail the advent of 
this work, for it fills a wide gap on the list of text- 
books for our schools, and is, for the practitioner, the 
most valuable practical work of its kind. — N. 0. Med. 
News. 



f>¥ THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
of 595 pages, cloth, $4 50. 

Dr. Flint's treatise is one of the most trustworthy 
guides which we can consult. The style is clear and 
distinct, and is also concise, being free from that tend- 
ency to over-refinement and unnecessary minuteness 
which characterizes many works on the same sub- 
ject.— Dublin Medical Press, Feb. 6, 1867. 

The chapter on Phthisis is replete with interest ; 
and his remarks on the diagnosis, especially in the 
early stages, are remarkable for their acumen and 
great practical value. Dr. Flint's style is ciear and 
elegant, and the tone of freshness and originality 



which pervades his whole work lend an additional 
force to its thoroughly practical character, which 
cannot fail to obtain for it a place as a standard work 
on diseases of the respiratory system. — London 
Lancet, Jan. 19, 1867. 

This is an admirable book. Excellent in detail and 
execution, nothing better could be desh-ed by the 
practitioner. Dr. Flint enriches his subject with 
much solid and not a little original observation.— 
Ranking 1 s Abstract, Jan. 1867. 



JDT THE SAME AUTHOR. (Ju«t Ready.) 

PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- 
ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- 
MENT, AND PHYSICAL DIAGNOSIS ; in a series of Clinical Studies. By Austin 
Flint, M.D., Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. 
College, New York. In one handsome octavo volume 

This volume, containing the results of the author's extended observation and experience on a 
subject of prime importance, cannot but have a claim upon the attention of every practitioner. 



JPULLER [HENRY WILLIAM), M. D., 

-*■ P7iysicia?i to St. George 1 s Hospital, London. 

ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their 

Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised 
English edition. In one handsome octavo volume of about 500 pages, cloth, $3 50. 



WILLIAMS [G. J. B.), M.D., 

Senior Consulting Physician to the Hospital for Consumption, Brompton, and 

'WILLIAMS [CHARLES T.), M.D., 

Physician to the Hospital for Consumption. 






PULMONARY CONSUMPTION; Its Nature, Varieties, and Treat- 
ment. With an Analysis of One Thousand Cases to exemplify its duration. In one neat 
octavo volume of about 350 pages, cloth, $2 50. (Lately Published.) 



He can still speak from a more enormous experi- 
ence, and a closer study of the morbid processes in- 
volved iu tuberculosis, than most living men. He 
owed it to himself, and to the importance of the sub- 
ject, to embody his views in a separate work, and 
we are glad that he has accomplished this duty. 



After all, the grand teaching which Dr Williams has 
for the profession is to be found in his therapeutical 
chapters, and in the history of individual cases ex- 
tended, by din t of care, over ten, twenty, thirty, and 
aven forty years. — London Lancet, Oct. 21, 1871. 



LA ROCHE ON PNEUMONIA. 1 vol. 8vo., cloth, 

of 500 pages . Price $3 00. 
SMITH ON CONSUMPTION ; ITS EARLY AND RE 

MEDIABLE STAGES. 1 vol. 8vo., pp. 254. $2 26. 



WALSHE ON THE DISEASES OF THE HEART AND 
GREAT VESSELS. Third American edition. In 
1 vol. 8vo., 420 pp., cloth. $3 00. 



18 



Henry C. Lea's Publications — {Practice of Medicine). 



ROBERTS ( WILLIAM), M. D., 

•*•*' Lecturer on Medicine in the Manchester School of Medicine, &c. 

A PRACTICAL TREATISE ON URINARY AND RENAL DIS- 

EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Sec- 
ond American, from the Second Revised and Enlarged London Edition. In one large 
and handsome octavo volume of 616 pages, with a colored plate ; cloth, $4 50. (Lately 
Published.) 
The author has subjected this work to a very thorough revision, and has sought to embody in 
it the results of the latest experience and investigations. Although every effort has been made 
to keep it within the limits of its former size, it has been enlarged by a hundred pages, many 
new wood-cuts have been introduced, and also a colored plate representing the appearance of the 
different varieties of urine, while the price has been retained at the former very moderate rate. 

diseases we have examined. It is peculiarly adapted 



The plan, it will thus be seen, is very complete, 
and the manner in which it has been carried out is 
in the highest degree satisfactory. The characters 
of the different deposits are very well described, and 
the microscopic appearances they present are illus- 
trated by numerous well executed- engravings. It 
only remains to us to strongly recommend to our 
readers Dr. Roberts's work, as containing au admira- 
ble resume of the present state of knowledge of uri- 
nary diseases, and as a safe and reliable guide to the 
clinical observer. — Edin. Med. Jour. 

The most complete and practical treatise upon renal 



to the wants of the majority of American practition- 
ers from its clearness and simple announcement of the 
facts in relation to diagnosis and treatment of urinary 
disorders, and contains in condensed form the investi- 
gations of Beuce Jones, Bird, Beale, Hassall. Prout, 
and a host of other well-known writers upon this sub- 
ject. The characters of urine, physiological and pa- 
thological, as indicated to the naked eye as well as by 
microscopical and chemical investigations, are con- 
cisely represented both by description and by well 
executed engravings. — Cincinnati Journ. of Med. 



jyASHAM ( W. R.), M. D., 

■*-* Senior Physician to the Westminster Hospital, &c. 



RENAL DISEASES : a Clinical Guide to their Diagnosis and Treatment. 

With illustrations. In one neat royal 12mo. volume of 304 pages, cloth, $2 00. 

details of larger books here acquire a new interest 
from the author's arrangement. This part of the 
book is full of good work. — Brit, and For. Medico- 
Ihirurgical Review, July, 1870. 



The chapters on diagnosis and treatment are very 
good, and the student and young practitioner will 
find them full of valuable practical hints. The third 
part, on the urine, is excellent, and we cordially 
recommend its perusal. The author has arranged 
his matter in a somewhat novel, and, we think, use- 
ful form. Here everything can be easily found, and, 
what is more important, easily read, for all the dry 



The easy descriptions and compact modes of state- 
ment render the book pleasingand convenient. — Am. 
Journ. Med. Sciences, July, 1870. 



INCOLN (D. F.). 31. D., 

Physician to the Department of Nervous Diseases, Boston Dispensary. 

ELECTRO THERAPEUTICS; 4 Concise Manual of Medical Electri- 
city. In one very neat royal 12mo. volume, cloth, with illustrations, $1 50. (Just Issued.) 



The work is convenient in size, its descriptions of 
methods and appliances are sufficiently complete for 
the general practitioner, and the chapters on Electro- 
physiology and diagnosis are well written and read- 
able. For those who wish a handy-book of directions 
for the employment of galvanism in medicine, this 
will serve as a very good and reliable guide. — New 
Remedies, Oct. 1874. 

It is a well written work, and calculated to meet 
the demands of the busy practitioner. It contains 
the latest researches in this important branch of med- 
icine. — Peninsular Journ. of Med., Oct. 1S74. 

Eminently practical in character. It will amply 
repay any one for a careful perusal. — Leavenworth 
Med. Herald, Oct. 1874. 



This little book is, considering its size, one of the 
very best of the English treatises on its subject that 
has come to our notice, possessing, among others, the 
rare merit of dealing avowedly and actually with 
principles, mainly, rather than with practical details, 
thereby supplying a real waut, instead -of helping 
merely to flood the literary market. Dr. Lincoln's 
style is usually remarkably clear, and the whole 
book is readable and interesting. — Boston Med. and 
Surg. Journ., July 23, 1874. 

We have here in a small compass a great deal of 
valuable information upon the subject of Medical 
Electricity. — Canada Med. and Surg. Journ.. Nov. 
1874. 



L 



EE [HENRY), 

Prof, of Surgery at the Royal College of Surgeons of England, etc. 

LECTURES ON SYPHILIS AND ON SOME FORMS OP LOCAL 

DISEASE AFFECTING PRINCIPALLY THE ORGANS OF GENERATION. In one 

handsome octavo volume : cloth; $2 25. (Now Ready.) 
CONTENTS. 

Lectures I., II., III. General. — IV. Treatment of Syphilis — V. Treatment of Particular 
and Modified Syphilitic Affections — VI. Second Stage of Lues Venerea; Treatment — VII. Lo- 
cal Suppurating Venereal Sore; Syphilization ; Lymphatic Absorption ; Physiological Absorp- 
tion ; Twofold Inoculation — VIII. Urethral Discharges : different kinds ; Treatment; Conclu- 
sions of Hunter and Ricord — IX. Prostatic Discharges — X. Lymphatic Absorption continued ; 
Local Affections ; Warts and Excrescences. 



DIPHTHERIA ; its Nature and Treat -nent, with an 
account of the History of its Prevalence in vari- 
ous Countries. By D. D. Slade, M.D. Second and 
revised edition. In one neat royal 12mo. volume, 
cloth, $1 25. 

LECTURES ON THE STUDY OF FEVER. By A. 
Hudson, M.D., M.R.I.A., Physician to the Meath 
Hospital. In one vol. 8vo., cloth, $2 50. 



A TREATISE ON FEVER. By Robert D. Lyons, 
K C C. In one octavo volume of 362 pages, cloth, 
$2 25. 

CLINICAL OBSERVATIONS ON FUNCTIONAL 
NERVOUS DISORDERS ByO. Hanofield Jones, 
M.D., Physician to St. Mary's Hospital, &c. Sec- 
ond American Edition. In one handsome octavo 
volume of 348 pages, cloth, $3 25. 



Henry C. Lea's Publications— ( Venereal Diseases, etc.). 



19 



T>UMSTEAD {FREEMAN J.), M.D., 

J~* Professor of Venereal Diseases at the Col. of Phys. and Surg., New York, &c. 

THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- 

EASES. Including the results of recent investigations upon the subject. Third edition, 

revised and enlarged, with illustrations. In one large and handsome octavo volume of 

over 700 pages, cloth, $5 00 ; leather, $6 00. 

In preparing this standard work again for the press, the author has subjected it to a very 

thorough revision. Many portions have been rewritten, and much new matter added, in order to 

bring it completely on a level with the most advanced condition of syphilograpby, but by careful 

compression of the text of previous editions, the work has been increased by only sixty-four pages. 

The labor thus bestowed upon it, it is hoped, will insure for it a continuance of its position as a 

complete and trustworthy guide for the practitioner. 



It is the most complete book with which we are ac- 
quainted in the language. The latest views of the 
best authorities are put forward, and the information 
Is well arranged — a great point for the student, and 
still more for the practitioner. The subjects of vis- 
ceral syphilis, syphilitic affections of the eyes, and 
the treatment of syphiiis by repeated inoculations, are 
very fully discussed. — London Lancet, Jan. 7, 1871. 

Dr. Bumstead's work is already so universally 
known as the best treatise in the English language on 
venereal diseases, that it may seem almost superflu- 
ous to say more of it than that a new edition has been 
Issued. But the author's industry has rendered this 
new edition virtually a new work, and so merits as 



(1ULLERIER (A.), and 

^•S Surgeon to the Hdpital du Midi. 



much special commendation as if its predecessors had 
not been published. As a thoroughly practical book 
on a class of diseases which form a large share of 
nearly every physician's practice, the volume before 
us is bv far the best of which we have knowledge. — 
N. Y. Medical Gazette, Jan. 28, 1871. 

It is rare in the history of medicine to find any one 
book which contains all that a practitioner needs to 
know; while the possessor of "Bumstead on Vene- 
real" has no occasion to look outside of its covers for 
anything practical connected with the diagnosis, his- 
tory, or treatment of these affections. — N. Y. Medical 
Journal, March, 1871. 



J?UMSTEAD [FREEMAN J.), 

-*-* Professor of Venerea I Diseases in the College of 
Physicians and Surgeons, N. Y. 

AN ATLAS OF VENEREAL DISEASES. Translated and Edited by 

Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, 
with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers for mailing, at $3 
per part. 
Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- 
lars a Part, thus placing it within the reach of all who are interested in this department of prac- 
tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. 
A specimen of the plates and text sent free by mail, on receipt of 25 cents. 



We wish for once that our province was not restrict- 
ed to methods of treatment, that we might say some- 
thing of the exquisite colored plates in this volume. 
—London Practitioner, May, 1869. 

As a whole, it teaches all that can be taught by 
means of plates and print. — London Lancet, March 
13, 1869. 

Superior to anything of the kind ever before issued 
on this continent.— Canada Med. Journal, March, '69. 

The practitioner who desires to understand this 
branch of medicine thoroughly should obtain this, 
the most complete and best work ever published.— 
Dominion Med. Journal, May, 1869. 

This is a work of master hands on both sides. M. 
Cullerier is scarcely second to, we think we may truly 
say is a peer of the illustrious and venerable Ricord, 
while in this country we do not hesitate to say that 
Dr. Bumstead, as an authority, is without a rival. 
Assuring our readers that these illustrations tell the 
whole history of venereal disease, from its inception 
to its end, we do not know a single medical work, 



which for its kind is more necessary for them to have. 
—California Med. Gazette, March, 1869. 

The most splendidly illustrated work in the lan- 
guage, and in our opinion far more useful than the 
French original. — Am. Journ. Med. Sciences, Jan. '69. 

The fifth and concluding number of this magnificent 
work has reached us, and we have no hesitation in 
saying that its illustrations surpass those of previous 
numbers. — Boston Med. and Surg. Journal, Jan. 14, 
1869. 

Other writers besides M. Cullerier have given us a 
good account of the diseases of which he treats, but 
no one has furnished us with such a complete series 
of illustrations of the venereal diseases. There is, 
however, an additional interest and value possessed 
by the volume before us ; for it is an American reprint 
and translation of M. Cullerier's work, with inci- 
dental remarks by one of the most eminent American 
syphilographers, Mr. Bumstead. — Brit, and For. 
Medico-Chir. Review, July, 1869. 



IF 



LL {BERKELEY), 

Surgeon to the Lock Hospital, London. 

ON SYPHILIS AND LOCAL 

one handsome octavo volume ; cloth, $3 

Bringing, as it does, the entire literature of the dis- 
ease down to the present day, and giving with great 
ability the results of modern research, it is in every 
respect a most desirable work, and one which should 
find a place in the library of every surgeon. — Cali- 
fornia Med. Gazette, June, 1869. 

Considering the scope of the book and the careful 
attention to the manifold aspects and details of its 
subject, it is wonderfully concise. All these qualities 
render it an especially valuable book to the beginner, 



CONTAGIOUS DISORDERS. In 

25. 

to whom we would most earnestly recommend its 
study ; while it is no less useful to the practitioner.— 
St. Louis Med. and Surg. Journal, May, 1869. 

The most convenient and ready book of reference 
we have met with.— N. Y. Med. Record, May 1, 1869. 

Most admirably arranged for both student and prac- 
titioner, no other work on the subject equals it ; it is 
more simple, more easily studied. — Buffalo Med. and 
Surg. Journal, March, 1869. 



yEISSL (#.), M.D. 

A COMPLETE TREATISE ON VENEREAL DISEASES. Trans- 
lated from the Second Enlarged German Edition, by Frederic It. Sturgis, M.D In one 
octavo volume, with illustrations. (Preparing.) 



§0 



Henry C. Lea's Publications— (Diseases of the Skin). 



VITILSON {ERASMUS), F.R.S. 

ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- 

enth American, from the sixth and enlarged English edition. In one large octavo volume 
of over 800 pages, $5. 

A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- 
EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- 
teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin } 
and embracing accurate representations of about one hundred varieties of disease, most of 
them the size of nature. Price, in extra cloth, $5 50. 
the Text and Plates, bound in one handsome volume. Cloth, $10. 

and acceptable help. Mr. Wilson has long been held 
as high authority in this department of medicine, and 
his book on diseases of the skin has long been re- 
garded as one of the best text-books extant on the 
subject. The present edition is carefully prepared, 
and brought up in its revision to the present time. In 
ohis edition we have also included the beautiful series 
of plates illustrative of the text, and in the last edi- 
tion published separately. There are twenty of these 
plates, nearly all of them colored to nature, and ex- 
hibiting with great fidelity the various groups of 
diseases. — Cincinnati Lancet. 



Also 

No one treating skin diseases should be without 
a copy of this standard work. — Canada Lancet. 

We can safely recommend it to the profession at 
the best work on the subject now in existence ir 
the English language.— Medical Times and Gazette 

Mr. Wilson's volume is an excellent digest of the 
actual amount of knowledge of cutaneous diseases : 
it includes almost every fact or opinion of importance 
connected with the anatomy and pathology of the 
skin. — British and Foreign Medical Review. 

Such a work as the one before us is a most capital 

j^F THE SAME AUTHOR. 

THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- 

eases of the skin. In one very handsome royal 12mo. volume. $3 50. 



fflELIGAN [J. MOORE), M.D., M.R.I. A. 

A PRACTICAL TREATISE ON DISEASES 



OF 



Fifth American, from the second and enlarged Dublin edition by T. 
In one neat royal 12mo. volume of 462 pages, cloth, $2 25. 



THE SKIN, 

W. Belcher, M.B. 



their value justly estimated; in a word, the work is 
fully up to the times, and is thoroughly stocked with 
most valuable information. — New York Med. Record, 
Jan. 15, 1867. 
The most convenient manual of diseases of the 

Chicago 



Fully equal to all the requirements of students and 
young practitioners. — Dublin Med. Press. 

Of the remainder of the work we have nothing be- 
yond unqualified commendation to offer. It is so far 
the most complete one of its size that has appeared, 

and for the student there can be none which can com- skin that can be procured by the student, 
pare with it in practical value. All the late disco- Med. Journal, Dec. 1866. 
veries in Dermatology have been duly noticed, and 1 
£ Y THE SAME AUTHOR. 

ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto 

volume, with exquisitely colored plates, <tc, presenting about one hundred varieties of 
disease. Cloth, $5 50. 



The diagnosis of eruptive disease, however, under 
all circumstances, is very difficult. Nevertheless, 
Dr. Neligan has certainly, "as far as possible," given 
a faithful and accurate representation of this class of 
diseases, and there can be no doubt that these plates 
will be of great use to the student and practitioner in 
di'awing a diagnosis as to the class, order, and species 
to which the particular case may belong. While 
looking over the "Atlas" we have been induced to 
examine also the "Practical Treatise," and we are 



inclined to consider it a very superior work, com- 
bining accurate verbal description with sound views 
of the pathology and treatment of eruptive disease*. 
— Glasgow Med. Journal. 

A compend which will very much aid the practi- 
tioner in this difficult branch of diagnosis. Taken 
with the beautiful plates of the Atlas, which are re- 
markable for their accuracy and beauty of coloring, 
it constitutes a very valuable addition to the library 
of a practical man. — Buffalo Med. Journal. 



ZJILLIER [THOMAS), M.D., 

■**•-*■ Physician to the Skin Department of University College Hospital, &c 

HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. 

Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrations. 

Cloth, $2 25. 
We can conscientiously recommend it to the stu- 
dent; the style is clear and pleasant to read, the 
matter is good, and the descriptions of disease, with 
the modes of treatment recommended, are frequently 
Illustrated with well-recorded cases. — London Med. 
Times and Gazette. April 1, 1865. 



It is a concise, plain, practical treatise on the vari- 
ous diseases of the skin ; just such a work, indeed, 
as was much needed, both by medical students and 
practitioners. — Chicago Medical Examiner, May, 
1865. 



ANDERSON [McCALL), M.D., 

•£*- Physician to the Dispensary for Skin Diseases, Glasgow, &c. 

ON THE TREATMENT OF DISEASES OF THE SKIN. With an 

Analysis of Eleven Thousand Consecutive Cases. In one vol. 8vo. $1. {Lately Published.) 

GUERSANT'S SURGICAL DISEASES OF INFANTS I DEWEES ON THE PHYSICAL AND MEDICAL 
AND CHILDREN. Translated by R. J. DtTXGM- TREATMEN'" 'W!H T T.ORlStf El<w„ n th edition. 
son, M.D. 1 vol. 8vo. Cloth, $2 50. | 1 v©i. Svo. of 548 pages. Cloth, $2 80. 



Henry C. Lea's Publications-— (Diseases of Children). 31 

&MITH {J. LE WIS), M. D., 

A-' Professor of Morbid Anatomy in the Bellevue Hospital Med. College, N. Y. 

A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF 

CHILDREN. Third Edition, revised and enlarged. In one handsome octave volume. 
(Preparing.) 

From the Preface to the Second Edition. 

In presenting to the profession the second edition of his work, the author gratefully acknow- 
ledges the favorable reception accorded to the first. He has endeavored to merit a continuance 
of this approbation by rendering the volume much more complete than before. Nearly twenty 
additional diseases have been treated of, among which may be named Diseases Incidental to 
Birth, Rachitis, Tuberculosis, Scrofula, Intermittent, Remittent, and Typhoid Fevers, Chorea, 
and the various forms of Paralysis. Many new formulae, which experience has shown to be 
useful, have been introduced, portions of the text of a less practical nature have been con- 
densed, and other portions, especially those relating to pathological histology, have .been 
rewritten to correspond with recent discoveries. Every effort has been made, however, to avoid 
an undue enlargement of the volume, but, notwithstanding this, and an increase in the size of 
the page, the number of pages has been enlarged by more than one hundred. 

227 West 49th Street, New York, April, 1872. 

The work will be found to contain nearly one-third more matter than the previous edition, and 
it is confidently presented as in every respect worthy to be received as the standard American 
text-book on the subject. 



Eminently practical as well as judicious in its 
teachings. — Cincinnati Lancet and Ohs., July, 1872. 

A standard work that leaves little to be desired. — 
Indiana Journal of Medicine, July, 1872. 

We know of no book on tbis subject that we can 
more cordially recommend to the medical student 
and thepractitioner.— Cincinnati Clinic, June 29, '72. 



We regard it as superior to auy other single work 
on the diseases of iufancy and childhood. — Detroit 
Rev. of Med. and Pharmacy, Aug. 1872. 

We confess to increased enthusiasm in recommend- 
ing this second edition. — St Louis Med. and Surg. 
Journal, Aug. 1S72. 



fJONDIE {D. FRANCIS), 31. D. 

A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. 

Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- 
printed pages, cloth, $5 25 ; leather, $6 25. 
The present edition, which is the sixth, is fully up 
to the times in the discussion of all those points in the 
pathology and treatment of infantile diseases which 



kave been brought forward by the Germau and French 



teachers. As a whole, however, the work is the best 
American one that we have, and in its special adapta- 
tion to American practitioners it certainly has no 
equal. — New York Med. Record, March 2, 1868. 



WEST {CHARLES), M.D., 

* " Physician to the Hospital for Sick Children, &c. 

LECTURES ON THE DISEASES OF INFANCY AND CHILD- 
HOOD. Fifth American from the sixth revised and enlarged English edition. In one large 
and handsome octavo volume of 678 pages. Cloth, $4 50 ; leather, $5 50. (Just Issued.) 
The continued demand for this work on both sides of the Atlantic, and its translation into Ger- 
man, French, Italian, Danish', Dutch, and Russian, show that it fills satisfactorily a want exten- 
sively feU by the profession. There is probably no man living who can speak with the authority 
derived from a more extended experience than Dr. West, and his work now presents the results of 
nearly 2000 recorded cases, and 600 post-mortem examinations selected from among nearly 40,000 
cases which have passed under his care. In the preparation of the present edition he has' omitted 
much that appeared of minor importance, in order to find room for the introduction of additional 
matter, and the volume, while thoroughly revised, is therefore not increased materially in size. 

Of all the English writers on the diseases of chil- I living authorities in the difficult department of medl- 
dren, there is no one so entirely satisfactory to us as | cal science in which he is most widely known.— • 
£»r. West. For years we have held his opinion as I Boston Med. and Surg. Journal. 
judicial, and have regarded Mm as one of the highest | 

£>Y THE SAME AUTHOR. (Lately Issued ) 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- 

HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- 
don, in March, 1871. In one volume, small 12mo., cloth, $1 00. 

jgMITH (EUSTACE), M. D^~ 

Physician to the Northwest London Free Dispensary for Sick Children. 

A PRACTICAL TREATISE ON THE WASTING DISEASES OF 

INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged 
English edition. In one handsome octavo volume, cloth, $2 50. (Lately Issued.) 

scribed as a practical handbook of the common dis- 
eases of children, so numerous are the affections con- 
sidered either collaterally or directly. We are 
acquainted with no safer guide to the treatment of 
children's diseases, and few works give the insight 
into the physiological and other peculiarities of chil- 
dren that Dr. Smith's book does.— Brit. Med. Journ., 



This is in every way an admirable book. The 
modest title which the author has chosen for it scarce- 
ly conveys an adequate idea of the manybubjects 
upon which it treats. Wasting is so constant an at- 
tendant upon the maladies of childhood, that a trea- 
tise upon the wasting diseases of children must neces 
uarily embrace the consideration of many affections 
of which it is a symptom ; and this is excellently well 
doae by Dr. Smith. The book might fairly be de- 



April 8, 1871. 



22 



Henry C. Lea's Publications — (Diseases of Women). 



rJWE OBSTETRICAL JOURNAL. {Free of pontage/or 187G.) 

THE OBSTETRICAL JOURNAL of Qreat Britain and Ireland; 

Including Midwikeky, and the Diseases of Women and Infants. With sin American 
Supplement, edited by J. V. InGHAM, M.D. A monthly of about 80 ootnvo. pages, 
very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 
cents each. 

Commencing with April, 1873, the Obstetrical Journal consists of Original Papers by Brit- 
ish and Foreign Contributors ; Transactions of the Obstetrical Societies in England and abroad ; 
Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and Notes, Edito- 
rial, Historical, Forensic, and Miscellaneous j Selections from Journals; Correspondence, &o. 
Collecting together the vast amount of material daily accumulating in this important and ra- 
pidly improving department of medical science, the value of the information which it pre- 
sents to the subscriber may be estimated from the character of the gentlemen who have already 
promised (heir support, including such names as those of Drs. ATTHILL, ROBERT Baunks, IIknry 
Bennkt, Thomas CHAMBERS, FLEETWOOD CHURCHILL, MATTHEWS DtTNOAN, Ouaii.y IIhwitt, 

Braxton Hicks, Alfred Meadows, W. Leishman, Alex. Simpson, Ttlbr Smith, Ddward J. 

Tilt, Spencer Wells, &c. Ac. ; in short, the representative men of British Obstetrics and Gynae- 
cology. 

In order to render the Obstetrical Journal fully adoquate to the wants of the American 
profession, each number contains a Supplement devoted to the advances made in Obstetrics and 
Gynecology on this side of the Atlantic. This portion of the Journal is under the editorial 
charge of Dr. J. V. Ingham, to whom editorial communications, exohanges, books for re- 
view, Ac, may be addressed, to the care of the publisher. 

*#* Complete sets from the beginning can no longer be furnished, but subscriptions can com- 
mence with January, 1875, or with Vol. II., April, 1871. 



rpHOMAS {T.GAILLARD),M.D. t 

Prqfe880r of Obstetrics, &c, in the. College of Physicians and Surgeons, N. Y., &c, 

A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth 

edition, enlarged and thoroughly revised. In one large and handsome ootavo volume of 

800 pages, with 191 illustrations. Cloth, $5 00; leather, $6 00. (Just Issued.) 

The author has taken advantage of the Opportunity a Horded by the call for another edition of 

this work to render it worthy a continuance of the very remarkable favor with which it has been 

received. Every portion has been subjected to a conscientious revision, and no labor has been 

spared to make it a complete treatise on the most advanced condition of its important subject. 

Am. Jouru. of obstetrics, 



A work winch has reached a fourth edition, and 
that, t oo, Id the short Bpaoe offlve years has achieved 
a reputation which places it almost beyond the 
reach of criticism, and the favorable opinions which 
we have already expressed of the former editions 
seem to require that we should <li> little more than 
announce this new issue. Wo cannot refrain from 
saying that, as a practical work, this is seoond to 
none in the English, or, indeed, in any other Lan- 
guage. Tim arrangement of I be contents, the admi- 
rably clear manner in which the Subject of the dif- 
ferential diagnosis of several of tim diseases is 
bandied, leave nothing to he desired by the praoti- 
tiouer who wants a thoroughly clinical work, one 
to which he can refer in difficult oases of doubtful 
diagnosis with the certainty of gaining light and 
Instruction Dr. Thomas is a man with a very clear 
bead and decided views, and there seems to be no- 
thing which he so niurli dislikes as hazy notions of 

diagnosis and blind routine and unreasonable thera- 
peutics. The student who will thoroughly study 
this i) ink and test its principles by clinical observa- 
tion, will certainly not be guilty of these faults.— 
London Lancet, Feb. 13, 1875. 

The latest edition of this well-known text-book 
retains the essential characters which rendered the 
earliost so deservedly popular It is still pre-emi- 
nently a practical manual, intended to convey fco 
students in a clear and forcible manner a sufficiently 
complete outline of gynaecology. In a word, we 
should s.i v that anyone who intended tO make a 

special study of gynaecology could hardly do better 
than to begin with a minute perusal of this hook, and 
that any one who intended to keep gynaecology sub- 
ordinate to general practice, should hardly fail to 
have it on hand for future reference. — N. Y. Med. 
Journ , Jan. 1875. 

Reluctantly we are obliged to close this unsatis- 
factory notice of so excellent a work, and in conclu- 
sion would remark that, as a teacher of gynecology, 
both didactic and clinical, Prof. Thomas has cer- 
tainly taken the lead far ahead of his confreres, 
and as an author he certaiuly has met with unusual 



and merited suocess.- 
Nov. 1874. 

This volume of l'rof. Thomas in its revised form 

is classical without being pedantic, full In the details 

Of anatomy and pathology, without ponderous 

translation of pages of German literature, describes 
distinctly the details and difficulties of each opera 
tion, without wearying and useless tninatlao, and is 

in all respects a, work worthy Of confidence, justify- 
ing the high regard In which Its distinguished au- 
thor is held by the profession. — Am. Supplement, 

Obstet. Journ., Oct. 1874. 

Professor Thomas fairly took the Profession of the 

Dnlted BtateS by storm when his hook first m;vde Its 
appearance early in IS68. Its reception was simply 
enthusiastic, notwithstanding a low adverse criti- 
cisms from our transatlantic brethren, the tirst large 
edition was rapidly exhausted, and in six mouths a 
second one was issued, and in two years a third one 

was announced and published, and wears now pro- 
mised the fourth. The popularity of this work was 
not ephemeral, and its success w<\^ unprecedented In 
the aunalsof American medical literature. Six years 
is a long period in medical scientific research, hut 
Thomas's work on " Diseases of Women" is still the 
leading native production of the United States. This 
order, the matter, the absence of theoretical disputa- 

tlveness, the fairness of statement, and the el 
of diction, preserved throughout the entire i 

the book, indicate that Professor Thomas did not 
overestimate his powers when ho conceived th 
and executed the work of producing a new treatise 
upon diseases of women. — PROP. I'ali.kn, in Louis- 
ville Med. Journal, Sept. 1874. 

Upon looking the work over, we think we can ea- 
sily BOS why it Should be popular. It is ideal - and 
simple in style, and, in the host sense of the word, 
practical. The arrangement In also natural, and is 
especially full In the therapeutical department i d all 
our reading of such works as this we know of none 
other in any language that has made a more favor- 
able impression on on mind. — OhicaffO Journ. of 
Nervous and Mental J)is6'xses, Jan 1875. 



Henry C. Lea's Publications — (Diseases of Women). 



23 



ffODGE (HUGH L.), M.D., 

J 2 Emeritus Professor of Obstetrics, Ac, in the University of Pennsylvania. 

ON DISEASES PECULIAR TO WOMEN; including Displacements 

of the Uterus. With original illustrations. Second edition, revised and enlarged. In 
one beautifully printed octavo volume of 531 pages, cloth, $4 50. 



From Prof. W. H. Byford, of the Rtish Medical 
College, Chicago. 

The book bears the impress of a master hand, and 
must, as its predecessor, prove acceptable to the pro- 
fession. In diseases of women Dr. Hodge has estab- 
lished a school of treatment that has become world- 
wide in fame. 

Professor Hodge's work is truly an original one 
from beginning to end, consequently no one can pe- 
ruse its pages without learning something new. The 
book, which is by no means a large one, is divided into 
two grand sections, so to speak : first, that treating of 
the nervous sympathies of the uterus, and, secondly, 



that which speaks of the mechanical treatment of dis- 
placements of that organ. He is disposed, as a non- 
believer in the frequency of inflammations of the 
uterus, to take strong ground against many of the 
highest authorities in this branch of medicine, and 
the arguments which he offers in support of his posi- 
tion are, to say the least, well put. Numerous wood- 
cuts adorn this portion of the woi'k, and add incalcu- 
lably to the proper appreciation of the variously 
shaped instruments referred to by our author. As a 
contribution to the study of women's diseases, it is of 
great value, and is abundantly able to stand on its 
own merits.— N. Y. Medical Record, Sept. 15, 1868. 



W: 



EST (CHARLES), M.D. 

LECTURES ON THE DISEASES OF WOMEN. Third American, 

from the Third London edition. In one neat octavo volume of about 550 pages, cloth, 
$3 75 ; leather, $4 75. 

seeking truth, and one that will convince the student 



As a writer, Dr. West stands, in our opinion, se- 
cond only to Watson, the "Macaulay of Medicine ;" 
he possesses that happy faculty of clothing instruc- 
tion in easy garments ; combining pleasure with 
profit, he leads his pupils, in spite of the ancient pro- 
verb, along a royal road to learning. His work is one 
which will not satisfy the extreme on either side, but 
It is one that will please the great majority who are 



that he has committed himself to a candid, safe, and 
valuable guide. —N. A. Med.-Chirurg Review. 

We have to say of it, briefly and decidedly, that it 
is the best work on the subject in any langunge, and 
that it stamps Dr. West as the facile, princeps of 
British obstetric authors.— Edinburgh Med. Journal. 



J?ARNES [ROBERT), M.D., F.R. G.P., 

•*~* Obstetric Physician to St. Thomas's Hospital, Ac 

A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- 
CAL DISEASES OF WOMEN. In one handsome octavo volume of about 800 pages, with 
169 illustrations. Cloth, $5 00 ; leather, $6 00. (Just Issued.) 
The very complete scope of this volume and the manner in which it has been filled out, may 
be seen by the subjoined Summary of Contents. 

Introduction. Chapter I. Ovaries; Corpus Luteum. II. Fallopian Tubes. III. Shape of 
Uterine Cavity. IV. Structure of Uterus. V. The Vagina. VI. Examinations and Diagnosis. 
VII. Significance of Leucorrhoea. VIII. Discharges of Air. IX. Watery Discharges. X. Puru- 
lent Discharges. XI. Hemorrhagic Discharges, XII. Significance of Pain. XIII. Significance 
of Dyspareunia. XIV. Significance of Sterility. XV. Instrumental Diagnosis and Treatment. 
XVI. Diagnosis by the Touch, the Sound, the Speculum. XVII. Menstruation and its Disor- 
ders. XVIII. Amenorrhea. XIX. Amenorrhoea (continued). XX. Dysmenorrhoea. XXI. 
Ovarian Dysmenorrhoea, &c. XXII. Inflammatory Dysmenorrhoea. XXIII. Irregularities of 
Change of Life. XXIV. Relations between Menstruation and Diseases. XXV. Disorders of Old 
Age. XXVI. Ovary, Absence and Hernia of. XXVII. Ovary, Hemorrhage, &c, of. XXVIII. 
Ovary, Tubercle, Cancer, &c, of. XXIX. Ovarian Cystic Tumors. XXX. Dermoid Cysts of 
Ovary. XXXI. Ovarian Tumors, Prognosis of. XXXII. Diagnosis of Ovarian Tumors. XXXIII. 
Ovarian Cysts, Treatment of. XXXIV. Fallopian Tubes, Diseases of. XXXV. Broad Liga- 
ments, Diseases of. XXXVI. Extra-uterine Gestation. XXXVII. Special Pathology of Ute 
rus. XXXVIII General Uterine Pathology. XXXIX. Alterations of Blood Supply. XL. 
Metritis, Endometritis, <fcc. XLI. Pelvic Cellulitis and Peritonitis, &c. XLII. Hematocele, &o 
XLIII. Displacements of Uterus. XLIV. Displacements (continued). XLV. Retroversion and 
Retroflexion. XLVI. Inversion. XLVII. Uterine Tumors. XLVIII. Polypus Uteri. XLIX. 
Polypus Uteri (continued). L. Cancer. LI. Diseases of Vagina. LII. Diseases of the Vulva. 

mas, and Peaslee, as if these eminent men were his 
countrymen and colleagues, and gives thorn a credit 
which must be gratifying to every American physi- 
cian.— Am. Journ. Med. Set, April, 1874. 



Embodying the long experience and personal obser- 
vation of one of the greatest of living teachers in dis- 
eases of women, it seems pervaded by the presence 
of the author, who speaks directly to the reader, and 
Bpeaks, too, as one having authority, And yet, not- 
withstanding this distinct personality, there is noth- 
ing narrow as to time, place, or individuals, in the 
views presented, and in the instructions given; Dr. 
Barnes has been an attentive student, not only of Eu- 
ropean, but also of Americau literature, pertaining to 
diseases of females, and enriched^his own experience 
by treasures thence gathered ; he seems as familiar, 
for example, with the writings of Sims, Emmet, Tho- 



Throughout the whole book it is impossible not to 
feel that theauthor has spontaneously, conscientious- 
ly, and fearlessly performed his task. He goes direct 
to the point, and does not loiter on the way to gossip 
or quarrel with other authors. Dr. Barnes's book 
will be eagerly read all over the world, and will 
everywhere be admired for its comprehensiveness, 
honesty of purpose, and ability. — The Obstet. Journ. 
of Great Britain and Ireland, March, 1874. 



DEWEES'S TREATISE ON THE DISEASES OF FE 
MALES. With illustrations. Eleventh Edition, 
with the Author's last improvements and correc 
tions. In one octavo volume of 536 pages, with 
plates, cloth. $3 00. 

CHURCHILL ON THE PUERPERAL FEVER AND 
OTHER DISEASES PECULIAR TO WOMEN. 1 vol. 
8vo., pp. 450, cloth. $2 50. 



ASHWELL'S PRACTICAL TREATISE ON THE DIS- 
EASES PECULIAR TO WOMEN. Third American, 
from the Third and revised London edition. 1 vol. 
8vo., pp. 528, cloth. $3 50. 

MEIGS ON THE NATURE, SIGNS, AND TREAT- 
MENT OF CHILDBED FEVER. 1 vol. 8vo., pp. 
365, cloth. $2 00. 



24 



Henry C. Lea's Publications— {Midwifery). 



H 



ODGE {HUGH L.), M.D., 

Emeritus Professor of Midwifery, &c, in the University of Pennsylvania, &e. 

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- 

trated with large lithographic plates containing one hundred and fifty-nine figures from 
original photographs, and with numerous wood-cuts. In one large and beautifully printed 
quarto volume of 550 double-columned pages, strongly bound in cloth, $14. 

The work of Dr. Hodge is something more than a 
•Imple presentation of his particular views in the de- 
partment of Obstetrics; it is something more than an 
ordinary treatise on midwifery ; it is, in fact, a cyclo- 
paedia of midwifery. He has aimed to embody in a 
single volume the whole science and art of Obstetrics. 
An elaborate text is combined with accurate and va- 
ried pictorial illustrations, so that no fact or principle 
Is left unstated or unexplained. — Am. Med. Times, 
Sept. 3, 1864. 

We should like to analyze the remainder of this 
excellent work, but already has this review extended 
beyond our limited space. We cannot conclude this 
notice without referring to the excellent finish of the 
work. In typography it is not to be excelled ; the 
paper is superior to what is usually afforded by our 
American cousins, quite equal to the best of English 
books. The engravings and lithographs are most 
beautifully executed. The work recommends itself 
for its originality, and is in every way a most valu- 
able addition to those on the subject of obstetrics. — 
Canada Med. Journal, Oct. 1861 

It is very large, profusely and elegantly illustrated, 
and is fitted to take its place near the works of great 

obstetricians. Of the American works on the subject! — Glasgow Med. Journal, Oct. 1S64. 
It is decidedly the best. — Edinb. Med. Jour., Dec. '64.1 

%*% Specimens of the plates and letter-press will be forwarded to any address, free by mail, 
on receipt of six cents in postage stamps. 

WANNER (THOMAS H), M. D. 
ON THE SIGNS AND DISEASES OF PREGNANCY. First American 

from the Second and Enlarged English Edition. With four colored plates and illustrations 
on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. 
The very thorough revision the work has undergone 
has added greatly to its practical value, and increased 



We have examined Professor Hodge's work with 
great satisfaction ; every topic is elaborated most 
fully. The views of the author are comprehensive, 
and concisely stated. The rules of practice are judi- 
cious, and will enable the practitioner to meet every 
emergency of obstetric complication with confidence. 
— Chicago Med. Journal, Aug. 1864. 

More time than we have had at our disposal since 
we received the great work of Dr. Hodge is necessary 
to do it justice. It is undoubtedly by far the most 
original, complete, and carefully composed treatise 
on the principles and practice of Obstetrics which has 
ever been issued from the American press. — Pacific 
Med. and Surg. Journal, July, 1864. 

We have read Dr. Hodge's book with great plea- 
sure, and have much satisfaction in expressing our 
commendation of it as a whole. It is certainly highly 
instructive, and in the main, we believe, correct. The 
great attention which the author has devoted to the 
mechanism of parturition, taken along with the con- 
clusions at which he has arrived, point, we think, 
conclusively to the fact that, in Britain at least, thg 
loctrines of Naegele have been too blindly received. 



materially its efficiency as a guide to the student and 
to the young practitioner. — Am. Journ. Med. Sci., 
April, 1868. 

With the immense variety of subjects treated of 
and the ground which they are made to cover, the im- 
possibility of giving an extended review of this truly 
remarkable work must be apparent. We have not a 
single fault to find with it, and most heartily com- 
mend it to the careful study of every physician who 
would not only always be sure of his diagnosis of 



pregnancy, but always ready to treat all the nume- 
rous ailments that are, unfortunately for the civilized 
women of to-day, so commonly associated with the 
function.— N. T. Med. Record, March 16, 1S68. 

We recommend obstetrical students, young and 
old, to have this volume in their collections. It con- 
tains not only a fair statement of the signs, symptoms, 
and diseases of pregnancy, but comprises in addition 
much interesting relative matter that is not to be 
found in any other work that we can name. — Edin- 
burgh Med Journal, Jan. 1868. 



S WAYNE {JOSEPH GRIFFITHS), M. D., 

*-s Physician- Accoucheur to the British General Hospital, &c. 

OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 
MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised 
London Edition with Additions by E. R. Hcjtchins, M. D. With Illustrations. In one 
neat 12mo volume Cloth. $1 25 {Lately Issued.) 
#^* See p. 3 of this Catalogue for the terms on which this work is offered as a premium to 
subscribers to the "American Journal of the Medical Sciences." 

It is really a capital little compendium of the sub- i answers the purpose. It is not only valuable for 
ject, and we recommend young practitioners to buy it youug beginners, but no one who is not a proficient 
and carry it with them when called to attend cases of in the art of obstetrics should be without it, because 
labor. They can while away the otherwise tedious it condenses all that is necessary to know for ordi- 



hours of waiting, and thoroughly fix in their memo- 
ries the most important practical suggestions it con- 
tains. The American editor has materially added by 
his notes and the concluding chapters to the com- 
pleteness and general value of the book. — Chicago 
Med. Journal, Feb. 1870. 

The manual before us containsin exceedingly small 
compass — small enough to carry in the pocket — about 
all there is of obstetrics, condensed into a nutshell of 
Aphorisms. The illustrations are well selected, and 
serve as excellent reminders of the conduct of labor — 
regular and difficult. — Cincinnati Lancet, April, '70. 

'Hiis is a mostadmirablalit tie work, and completely 



nary midwifery practice. We commend the book 
most favorably. — St. Louis Med. and Surg. Journal, 
Sept. 10, 1870. 

A studied perusal of this little book has satisfied 
us of its eminently practical value. The object of the 
work, the author says, in his preface, is to give the 
student a few brief and practical directions respect- 
ing the management of ordinary cases of labor ; and 
also to poiut out to him in extraordinary cases whea 
and how he may act upon his own responsibility, and 
when he ought to send for assistance. — N. ¥. Medical 
Journal, May. 18^0 



w 



INCKEL (F.), 

Professor and Director of the Gynaecological Clinic in the University of Rostock. 

A COMPLETE TREATISE ON THE PATHOLOurF AND TREAT- 
MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent of 
the author, from the Second German Edition, by James Read Chadwick, M D. In one 
ootavo volume. (Preparing.) 



Hen&y C. Lea's Publications — {Midwifery), 



25 



T EISHMAN {WILLIAM), M.D., 






Regius Professor of Midwifery in the University of Glasgow, &c. 

SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 

PREGNANCY AND THE PUERPERAL STATE. Second American, from the Second 
and Revised English Edition, with additions by John S. Parry, M.D., Obstetrician to the 
Philadelphia Hospital, &c. In one large and very handsome octavo volume of over 700 
pages, with about two hundred illustrations. {Preparing.) 



This is one of a most complete and exhaustive cha- 
racter. We have gone carefully through it, and there 
is no subject in Obstetrics which has not been con- 
sidered well and fully. The result is a work, not 
only admirable as a text-book, but valuable as a work 
of reference to the practitioner in the various emer- 
gencies of obstetric practice. Take it all in all, we 
have no hesitation in saying that it is in our judgment 
the best English work on the subject. — London Lan- 
cet, Aug. 23, 1873. 

The work of Leishman gives an excellent view of 
modern midwifery, and evinces its author's extensive 
acquaintance with British and foreign literature ; and 
not only acquaintance with it, but wholesome diges- 
tion and sound judgment of it. He has, withal, a 
manly, free style, and can state a difficult and compli- 
cated matter with remarkable clearness and brevity. 
—Edin. Med. Journ., Sept. 1873. 

The author has succeeded in presenting to the pro- 
fession an admirable treatise, especially in its practi- 
cal aspects ; one which is, in general, clearly written, 
and sound in doctrine, and one which cannot fail to 
add to his already high reputation. In concluding 
our examination of this work, we cannot avoid again 
eaying that Dr. Leishman has fully accomplished 
that difficult task of presenting a good text-book upon 
obstetrics. We know none better for the use of the stu- 
dent or junior practitioner. — Am. Practitioner, Mar. 
1874. 

It proposes to offer to practitioners and students 



"A Complete System of the Midwifery of the Present 
Day," and well redeems the promise. In all that 
relates to the subject of labor, the teaching is admi- 
rably clear, concise, and practical, representing not 
alone British practice, but the contributions of Con- 
tinental and American schools. — N. Y. Med. Record, 
March 2, 1874. 

The work of Dr. Leishman is, in many respects, 
not only the best treatise on midwifery that we have 
seen, but one of the best treatises on any medical sub- 
ject that has been published of late years. — Land. 
Practitioner, Feb. 1874. 

It was written to supply a desideratum, and we will 
be much surprised if it does not fulfil the purpose of 
its author. Taking it as a whole, we know of no 
work on obstetrics by an English author in which the 
student and the practitioner will find the information 
so clear and so completely abi east of the present state 
of our knowledge on the subject.— Glasgow Med. 
Journ., Aug. 1873. 

Dr. Leishman's System of Midwifery, which has 
only just been published, will go far to supply the 
want which has so long been felt, of a really good 
modern English text-book. Although large, as is in- 
evitable in a work on so extensive a subject, it is so 
well and clearly written, that it is never wearisome 
to read. Dr. Leishman's work may be confidently 
recommended as an admirable text-book, and is sure 
to be largely used. — Lond. Med. Record, Sept. 1873. 



JDAMSBOTHAM {FRANCIS H.), M.D. 

THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 

CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged 
edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., 
Professor of Obstetrics, &c, in the Jefferson Medical College, Philadelphia. In one large 
and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
all nearly 200 large and beautiful figures. $7 00. 



We will only add that the student will learn from 
tt all he need to know, and the practitioner will find 
it, as a book of reference, surpassed by none other. — 
Stethoscope. 

The character and merits of Dr. Ramsbotham's 
work are so well known and thoroughly established, 
that comment is unnecessary and praise superlluous. 
The illustrations, which are numerous and accurate, 
are executed in the highest style of art. We cannot 
too highly recommend the work to our readers. — St. 
Louis Med. and Surg. Journal. 



To the physician's library it is indispensable, while 
to the student, as a text-book, from which to extract 
the material for laying the foundation of an ed ucation 
on obstetrical science, it has no superior. — Ohio Med. 
and Surg. Journal. 

When we call to mind the toil we underwent in 
acquiring a knowledge of this subject, we cannot but 
envy the student of the present day the aid which 
this work will afford him. — Am. Jour, of the Med. 
Sciences. 



QRURCHTLL {FLEETWOOD), M.D., M.R.I. A. 

ON THE THEORY AND PRACTICE OF MIDWIFERY. A new 

American from the fourth revised and enlarged London edition. With notes and additions 
by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Chil- 
dren,'' &c. With one hundred and ninety-four illustrations. In one very handsome octavo 
volume of nearly 700 large pages. Cloth, $4 00 ; leather, $5 00. 



T>ARRY [JOHN &), M.D., 

Obstetrician to the Philadelphia Hospital, Vice-Prest. of the Ob&tet. Society of Philadelphia 

EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, 

DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. 
(Preparing.) 



MONTGOMERY'S EXPOSITION OP THE SIGNS 
AND SYMPTOMS OF PREGNANCY. With two 
exquisite colored plates, and numerous wood cuts. 
In 1 vol. 8vo., of nearly 600 pp., cloth. $3 75. 



BIGBY'S SYSTEM OF MIDWIFERY. With Notes 
and Additional Illustrations. Second American, 
edition. One volume octavo, cloth, 422 pages. 
$2 60. 



26 



Henry C. Lea's Publications— (Surgery). 



6 1ROSS {SAMUEL J).), M.D., 
Professor of Surgery in the Jefferson Medical College of Philadelphia. 

A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, 

and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition, 
carefully revised, and improved. In two large and beautifully printed imperial octavo vol- 
umes of about 2300 pages, strongly bound in leather, with raised bands, $15. (Just Issued.) 
The continued favor, shown by the exhaustion of successive large editions of this great work, 
proves that it has successfully supplied a want felt by American practitioners and students. In the 
present revision no pains have been spared by the author to bring it in every respect fully up to 
the day. To effect this a large part of the work has been rewritten, and the whole enlarged by 
nearly one-fourth, notwithstanding which the price has been kept at its former very moderate 
rate. By the -use of a close, though very legible type, an unusually large amount of matter is 
condensed in its pages, the two volumes containing as much as four or five ordinary octavos. 
This, combined with the most careful mechanical execution, and its very durable binding, renders 
it one of the cheapest works accessible to the profession. Every subject properly belonging to the 
domain of surgery is treated in detail, so that the student who possesses this work may be said to 
have in it a surgical library. A few notices of the previous edition are subjoined : — 



It must long remain the most comprehensive work 
on this important part of medicine. — Boston Medical 
and Surgical Journal, March 23, 1865. 



We have compared it with most of our standard 
works, sach as those of Erichsen, Miller, Fergusson, 
Syme, and others, and we must, in justice to our 
author, award it the pre-eminence. As a work, com- 
plete in almost every detail, no matter how minute 
or trifling, and embracing every subject known in 
the principles and practice of surgery, we believe it 
stands without a rival. Dr. Gross, in his preface, re- 
marks "my aim has been to embrace the whole do- 
main of surgery, and to allot to every subject its 
legitimate claim to notice;" and, we assure our 
readers, he has kept his word. It is a work which 
we can most confidently recommend to our brethren, 
for its utility is becoming the more evident the longer 
it is upon the shelves of our library.— Canada Med. 
Journal, September, 1865. 

The first two editions of Professor Gross' System of 
Surgery are so well known to the profession, and so 
highly prized, that it would be idle for us to speak in 
praise of this work.— Chicago Medical Journal, 
September, 1865. 

We gladly indorse the favorable recommendation 
of the work, both as regards matter and style, which 
we made when noticing its first appearance.— British 
and Foreign Medico- Chirurgical Review, Oct. 1865. 

The most complete work that has yet issued from 
the press on the science and practice of surgery. — 
London Lancet. 

This system of surgery is, we predict, destined to 
take a commanding position in our surgical litera- 
ture, and be the crowning glory of the author's well 
earned fame. As an authority on general surgical 
subjects, this work is long to occupy a pre-eminent 
place, not only at home, but abroad. We have no 

1DY THE SAME AUTHOR. 

PRACTICAL TREATISE ON 



hesitation in pronouncing it without a rival in our 
language, and equal to the best systems of surgery in 
any language. — N. Y. Med. Journal. 

Not only by far the best text-book on the subject, 
as a whole, within the reach of American students, 
but one which will be much more than ever likely 
to be resorted to and regarded as a high authority 
abroad. — Am. Journal Med. Sciences, Jan. 1865. 

The work contains everything, minor and major, 
operative and diagnostic, including mensuration and 
examination, venereal diseases, and uterine manipu- 
lations and operations. It is a complete Thesaurus 
of modern surgery, where the student and practi- 
tioner shall not seek in vain for what they desire.— 
San Francisco Med. Press, Jan. 1865. 

Open it where we may, we find sound practical in- 
formation conveyed in plain language. This book i« 
no mere provincial or even national system of sur- 
gery, but a work which, while very largely indebted 
to the past, has a strong claim on the gratitude of the 
future of surgical science. — Edinburgh Med. Journal, 
Jan. 1865. 

A glance at the work is sufficient to show that the 
author and publisher have spared no labor in making 
it the most complete "System of Surgery" ever pub- 
lished in any country. — St. Louis Med. and Surg. 
Journal, April, 1865. 

A system of surgery which we think unrivalled in 
our language, and which will indelibly associate his 
name with surgical science. And what, in our opin- 
ion, enhances the value of the work is that, while the 
practising surgeon will find all that he requires in it, 
it is at the same time one of the most valuable trea- 
tises which can be put into the hands of the student 
seeking to know the principles and practice of this 
branch of the profession which he designs subse- 
quently to follow.— The Brit. Am.Journ., Montreal. 



A 



AIR-PASSAGES. In 1 vol. 8vo. 



FOREIGN BODIES IN THE 

with illustrations, pp. 468, cloth, $2 75. 



SKEY'S OPERATIVE SURGERY. In 1 vol. 8vo. 

cloth, of over 650 pages ; with about 100 wood-cuts. 

$3 25. 
COOPER'S LECTURES ON THE PRINCIPLES AND 

Practice of Surgery. In 1 vol. 8vo. cloth, 750 p. $2. 



GIBSON'S INSTITUTES AND PRACTICE OF 8US- 
gert. Eighth edition, improved and altered. With 
thirty-four plates. In two handsome octavo vol- 
umes, about 1000 pp. , leather, raised bandt . $6 60. 



M 



1LLER [JAMES), 

Late Professor of Surgery in the University of Edinburgh, &c. 

PRINCIPLES OE SURGERY. Fourth American, from the third and 

revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with 
two hundred and forty illustrations on wood, cloth, $3 75. 

UY THE SAME AUTHOR. 

THE PRACTICE OF SURGERY. Fourth American, from the last 

Edinburgh edition. Revised by the American editor. Illustrated by three hundred and 
sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, cloth, 
$3 75. 

QARGENT [F. W.), M.D. 
° ON BANDAGING AND OTHER OPERATIONS OF MINOR 

SURGERY. New edition, with an additional chapter on Military Surgery. One handsome 
royal 12mo. volume, of nearly 400 pages, with 184 wood-cuts. Cloth, $1 76. 



Henry C. Lea's Publications — (Surgery). 



2? 



ASEHURST {JOHN, Jr.), M.D., 

Surgeon to the Episcopal Hospital, Philadelphia. 

THE PRINCIPLES AND PRACTICE OF SURGERY. In one 

very large and handsome octavo volume of about 1000 pages, with nearly 550 illustrations, 

cloth, $6 50; leather, raised bands, $7 50. (Lately Published.) 
The object of the author has been to present, within as condensed a compass as possible, a 
Complete treatise on Surgery in all its branches, suitable both as a text-book for the student and 
a work of reference for the practitioner. So much has of late years been done for the advance- 
ment of Surgical Art and Science, that there seemed to be a want of a work which should present 
the latest aspects of every subject, and which, by its American character, should render accessible 
to the profession at large the experience of the practitioners of both hemispheres. This has been 
the aim of the author, and it is hoped that the volume will be found to fulfil its purpose satisfac- 
torily. 



Its author has evidently tested the writings and 
experiences of the past and present in the crucible 
of a careful, analytic, and honorable mind, and faith- 
fully endeavored to bring his work up to the level of 
the highest standard of practical surgery. He is 
frank and definite, and gives us opinions, and gene- 
rally sound ones, instead of a mere resume of the 
opinions of others. He is conservative, but not hide- 
bound by authority. His style is clear, elegant, and 
scholarly. The wcrk is anadmirable tex-tbook, and 
a useful book of reference It is a credit to American 
professional literature, and one of the first ripe fruits 
of the soil fertilized by the blood of our late unhappy 
war.— N. Y. Med. Record, Feb. 1, 1872. 



Indeed, the work as a whole must be regarded as 
an excellent and concise exponent of modern sur- 
gery, and as such it will be found a valuable text- 
book for the student, and a useful book of reference 
for the general practitioner. — N. Y. Med. Journal, 
Feb. 1S72. 

It gives us great pleasure to call the attention of the 
profession to this excellent work. Our knowledge of 
its talented and accomplished author led us to expect 
from him a very valuable treatise upon subjects to 
which he has repeatedly given evidence of having pro- 
fitably devoted much time and labor, and we are in no 
way disappointed.— Phila. Med. Times, Feb. 1, 1872. 



H 



OLMES {TIMOTHY), M.D., 

Surgeon to St. George's Hospital, London 

SURGERY, ITS PRINCIPLES 

some octavo volume of about 800 pages. 



AND PRACTICE. 

with over 400 illustrations. 



In one hand- 

( Nearly Ready.) 



DIRRIE ( WILLIAM), F. R. S. E., 

Professor of Surgery in the University of Aberdeen. 

THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by 

John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the 
Pennsylvania Hospital, &c. In one very handsome octavo volume of 780 pages, with 316 
illustrations, cloth, $3 75. 



JJAMILTON {FRANK H.), M.D., 

Professor of Fractures and Dislocations, &c, in Bellevue Hosp. Med. College, New York. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 

TIONS. Fifth edition, revised and improved. In one large and handsome octavo volume 
of nearly 800 pages, with 344 illustrations. Cloth, $5 75 ; leather, $6 75. (Nearly Ready. \ 
This work is well known, abroad as well as at home, as the highest authority on its important 
subject — an authority recognized in the courts as well as in the schools and in practice — and 
again manifested, not only by the demand for a fifth edition, but by arrangements now in pro- 
gress for the speedy appearance of a translation in Germany. The repeated revisions which the 
author has thus had the opportunity of making have enabled him to give the most careful consid- 
eration to every portion of the volume, and he has sedulously endeavored in the present issue, 
to perfect the work by the aid of his own enlarged experience and to incorporate in it whatever 
of value has been added in this department since the issue of the fourth edition. It will there- 
fore be found considerably improved in matter, while the most careful attention has been paid 
to the typographical execution, and the volume is presented to the profession in the confident 
hope that it will more than maintain its very distinguished reputation. 
A few notices of the previous edition are subjoined : — 



Prof. Hamilton has aworld-wide reputation as the 
author of a Treatise on Fractures and Dislocations, 
which it is safe to say has no equal in the English 
language. — Buffalo Med. and Surg. Journ., Nov. 
1872. 

The best work on the subject now published. — Am. 
Journ. of Med. Sci., Jan. 1S73. 

It is undoubtedly the best on those subjects in the 
English language — Nashville Med. and Surg. 
Journ., Dec. 1872. 

It is not, of course, our intention to review, in ex- 
tenso, Hamilton on "Fractures and Dislocations." 
Eleven years ago 6uch review might not have been 
out of place ; to-day the work is an authority, so well, 
so generally, and so favorably known, that it only 
remains for the reviewer to say that a new edition is 
Just out, and it is better than either of its predeces- 
sors.— Cincinnati Clinic, Oct. 1-1, 1871. 



Undoubtedly the best work on Fractures and Dis* 
locations in the English language. — Cincinnati Med. 
Repertory, Oct. 1871. 

We have once more before us Dr. Hamilton's admi- 
rable treatise, which we have always considered the 
most complete and reliable work on the subject. As 
a whole, the work is without an equal in the litera- 
ture of the profession. — Boston Med. and Surg. 
Journ., Oct. 12, 1871. 

It is unnecessary at this time to commend the book, 
except to such as are beginners in the study of this 
particular branch of surgery. Every practical sur- 
geon in this country and abroad knows of it as a most 
trustworthy guide, and one which they, in common 
with us, would unqualifiedly recommend as the high- 
est authority in any language.' — N. Y. Med. Record, 
Oct. 16, 1871. 



28 



Henry C. Lea's Publications — (Surgery). 



PRICHSHN {JOHN EX 
•*~ j ' Professor of Surgery in University College, London, etc 

THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- 

gioal Injuries, Diseases, and Operations. Revised by the author from the Sixth and 
enlarged English Edition. Illustrated by over .seven hundred engravings on wood. In 
two large and beautiful OOtavo Volumes of over 1700 pages, cloth, $0 00 ; leather, $1 1 00. 
(Lately Issued.) f 

Author's "Preface to the N/u> American Edition. 

u The favorable recent. ion with which the ' Science and Art of Surgery' has been honored by the 
Surgic&l Profession in the United States Of America has been not, only a source of deep gratifica- 
tion and of just pride to me, but has laid the foundation of many professional friendships that 
are amongst the agreeable and valued recollections of my life. 

"I h ;ivc endeavored to make the present edition of this work more deserving than its predecessor! 
of the favor that has been accorded to them. In oonsequenoe of delays that have unavoidably 

occurred in the publication of the Sixth British Edition, lime has been afforded to me to add to fh'iH 

one several paragraphs which 1 trust, will bo found to Increase the practical value of the work." 
London, Oct. 1872. 
On no former edition of this work has the author bestowed more pains to render it, a complete and 
satisfactory exposition of British Surgery in its modern aspeots. Every portion has been sedu- 
lously revised, :ind a large number ol new illustrations have been Introduced. I Q addition to the 
materia] thus added to the English edition, the author has furnished for the American edition such 
materia] as has aooumulated since the passage of the sheets through the press in London, so that 

the work as now presented to the American profession, oontains his latest views and experience. 
The increase in the size of the work has seemed to render necessary its division Into two vol- 
umes. Great care has keen exercised in its typographical execution, and it is confidently pre- 
sented as in every respect worthy to maintain the high reputation which has rendered it a stand* 

ard authority on this depart. menl of medical science. 

These are only a few of the points Id winch the 
present edition of Mr. Erichsen's work surpasses its 

predecessors. Throughout there is evidence Of ft 

laborious ca.ro a.ini Bolicltude in seizing the passing 
knowledge of the day, which reflects the greatest 
credit on the author, and muoh enhances the value 



of his work. We oan only ad mire the industry which 
has enabled Mr. Eriohsen thus to succeed, amid the 
distractions of active practice, In producing emphatic* 

al I y Tin', hook of reference and study for British prao- 
tltioners of surgery, London Lancet, Oct. 26, 1872 

Considerable changes have been made In this edi- 
tion, and nearly a. hundred 06W i 1 1 usl rai ions h.i ve 
I n 'on added. It is d i Hie u 1 1 in a small com pass lo point 
OUt I ho a Mora lion, and addition-, ; t'oi , a.s the author 



states In his preface, they are not confined to anyone 

portion, but are distributed generally through the 

Subjects Of Which the WOl'k treats. Certainly one of 

the most valuable seotions of the hook seems to us to 
be that which treats of the disease* of the arteries 
and the operative proceedings » inch i hey nee, 
in few text-books Is ho much carefully arranged Ln< 
formation collected. — London Med, Times ana Qa&., 
oet. 26, 1872. 

The entire work, complete, as the great English 
treatise on Burgei \ of our own tune, is, we oan asHure 
our readers, equally well adapted for the moat junior 

student, and, a; a, I k of reference, for the advanced 

practitioner — Dublin Quarterly ■lour mil. 



jHRUITT {ROBERT), 
THE PRINCIPLES 



All that the surgical student or pra 

desire. — Dublin. Quarterly Journal. 
It 1h a most admirable hook. We do not know 

when WO have examined one with more pleasure. — 

Boston Med. and Surg. Journal. 



M.R.C.S.,Src. 
AND PRACTICE OF MODERN SURGERY. 

A new and revised American, from the eighth enlarged and improved London edition. Illus- 
trated with four hundred and thirty -tWO WOOd engravings. In one very handsome octavo 
volume, of nearly 700 large and closely printed pages, cloth, $'l 00 j leather, $5 00. 

practice of surgery are treated, and 80 clearly and 

perspicuously, as to elnoldate every lmportai plo. 

We nave examined the hook most, thoroughly, and 

thai this SUCCesa is well merited, liis hooli, 

ir, possesses the Inestimable advant 
ia ring the Bubjeots perfect iy well arranged and olas< 

lifted, I of being written In a style at on 

uccinot,— Am, Journal of Med, Sciences. 



in Mr. Druitt's book, though containing only some 

eeven hundred pages, both the principles and the 



A 



SI J TON (T. J.). 



ON THE DISEASES, INJURIES, ANT) M AEFOK ,M ATIONH OF 
TIIM RECTUM A.ND ANUS; with remarks on Habitual Constipation. Second A morioan, 
from the fourth and enlarged London edition. With handsome illustrations. In one very 

beautifully printed octavo volume of ahoul 800 pages, cloth, $.'1 25. 



jyiQELO W [EENR Y ./.), M. />., 

LJf Professor of Surgery tn the Massachusetts Med, < 1 <>iU'ge.. 

ON THE MECHANISM OF DISLOCATION 



AND FRACTURE 



OF THE HIP. With the Reduction Of the Dislocation by the Flexion Method. With 
numerous original illustrations. In one very handsome octavo volume. Cloth, $2 50. 



T A WSON [GEORGE), F. R. C.S., Engl, 

J-J Assistant Surgeon to tin- Royal London Ophthalmic Hospital, Moor fields, &o. 

INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- 

diate and Remote Effects. With about one hundred illustrations. In one very hand- 
some octavo volume, cloth, %'A 50 
It is an admirable practical book la the highest nnd best khuha of t.br pbrano. — London Medical Times 
and f/azttte. May IB, 1867. 



Henry C. Lea's Publications-— (iSWgery). 



29 



T>RYANT {THOMAS), F.R.C.S., 

&-* Surgeon to Guy's Hospital. 

THE PRACTICE OF SURGERY. With over Five Hundred En- 

gravings on Wood. In one large and very handsome octavo volume of nearly 1000 pages, 
cloth, $6 25 ; leather, raised bands, $7 25. (Lately Published.) 

and fairly, yet it is no mere compilation. The book 
combines much of the merit of the manual with the 
merit of the monograph. One may recogui 



Again, the author gives us his own practice, his 
own beliefs, and illustrates by his own cases, or those 
treated in Guy's Hospital. This feature adds joint 
emphasis, and a solidity to his statements that inspire 
confidence. One feels himself almost by the side of 
the surgeon, seeing his work and hearing his living 
words. The views, etc., of other surgeons are con- 
sidered calmly and fairly, but Mr. Bryant'.s are 
adopted. Thus the work is not a compilation of 
other writings; it is not an encyclopedia, but the 
plain statements, on practical points, of a man who 
has lived and breathed and had his being in the 
richest surgical experience. The whole profession 
owe a debt of gratitude to Mr. Bryant, for his work 
in their behalf We are confident that the American 
profession will give substantial testimonial of their 
feelings towards both author and publisher, by 
speedily exhausting this edition. We cordially aud 
heartily commend it to our friends, and think that 
no live surgeon can afford to be without it. — Detroit 
Review of Med. and Pharmacy, August, 1873. 

As a manual of the practice of surgery for the use 
of the student, we do not hesitate to pronounce Mr. 
Bryant's book a first-rate work. Mr. Bryant has a 
good deal of the dogmatic energy which goes with 
the clear, pronounced opinions of a man whose re- 
flections and experience have moulded a character 
not wanting in firmness aud decision. At the same 
time he teaches with the enthusiasm of one who has 
faith in his teaching; he speaks as one having au- 
thority, and herein lies the charm aud excellence of 
his work. He states the opinions of others freely 



almost every chapter of the ninety-four of which the 
work is made up the acuteness of a surgeon who has 
seen much, and observed closely, and who gives forth 
the results of actual experience. In conclusion we 
repeat what we stated at first, that Mr. Bryant's book 
is one which we can conscientiously recommend both 
to practitioners and students as an admirable work. 
— Dublin Journ. of Med. Science, August, 1873. 

Mr. Bryant has long been known to the reading 
portion of the profession as an able, clear, and graphic 
writer upon surgical subjects. The volume before 
us is one eminently upon the practice of surgery and 
not one which treats at length on surgical pathology, 
though the views that are entertained upon tnis sub- 
ject are sufficiently interspersed through the work 
for all practical purposes. As a text-book we cheer- 
fully recommend it, feeling convinced that, from the 
subject-matter, and the concise and true way Mr. 
Bryant deals with his subject, it will prove a for- 
midable rival among the numerous surgical text- 
books which are offered to the student. — N. Y. Med. 
Record, June, 1873. 

This is, as the preface states, an entirely new book, 
and contains in a moderately condensed form all the 
surgical information necessary to a general practi- 
tioner. It is written in a spirit consistent with the 
present improved standard of medical and surgical 
science. — American Journal of Obstetrics, August, 
1S73. 



w 



ELLS [J. SOELBERG), 

Professor of Ophthalmology in King's College Hospital, Sec. 



A TREATISE ON DISEASES OF THE EYE. Second American, 

from the Third and Revised London Edition, with additions; illustrated with numerous 
engravings on wood, and six colored plates. Together with selections from the Test-types 
of Jaeger and Snellen. In one large and very handsome octavo volume of nearly 800 
pages; cloth, $5 00; leather, $6 00. {Lately Published.) 

The continued demand for this work, both in England and this country, is sufficient evidence 
that the author has succeeded in his effort to supply within a reasonable compass a full practical 
digest of ophthalmology in its most modern aspects, while the call for repeated editions has en- 
abled him in his revisions to maintain its position abreast of the most recent investigations and 
improvements. In again reprinting it, every effort has been made to adapt it thoroughly to the 
wants of the American practitioner. Such additions as seemed desirable have been introduced 
by the editor, Dr. I. Minis Hays, and the number of illustrations has been largely increased. The 
importance of test-types as an aid to diagnosis is so universally acknowledged at the present day 
that it seemed essential to the completeness of the work that they should be added, and as the 
author recommends the use of those both of Jaeger and of Snellen for different purposes, selec- 
tions have been made from each, so that the practitioner may have at command all the assist- 
ance necessary. Although enlarged by one hundred pages, it has been retained at the former 
very moderate price, rendering it one of the cheapest volumes before the profession. 

A few notices of the previous edition are subjoined. 

On examining it carefully, one is not at all sur- i lucid and flowing, therein differing materially from 
prised that it should meet with universal favor. It some of tlie translations of Continental writers on this 
is, in fact, a comprehensive and thoroughly practical subject that are in the market. Special pains are 
treatise on diseases of the eye, setting forth theprac- taken to explain, at length, those subjects which are 



tice of the leading oculists of Europe and America, 
aud giving the author's own opinions and preferences, 
which are quite decided and worthy of high consid- 
eration. The third English edition, from which this 
is taken, having been revised by the author, com- 
prises a notice of all the more recent advauces made 
in ophthalmic bciehee. The style of the writer is 



particularly difficult of comprehension to the begin- 
ner, as the use of the ophthalmoscope, the interpre- 
tation of its images, etc. The book is profusely and 
ably illustrated, and at the end are to be fouud 16 
excellent colored ophthalmoscopic figures, which are 
copies of some of the plates of Liebreich's admirable 
atlas.— Kansas City Med. Journ., June, 1874. 



' A URENCE {JOHN Z.), F. R. G. S., 

Editor of the Ophthalmic Review, &c. 

A HANDY-BOOK OF OPHTHALMIC* SURGERY, for the use of 

Practitioners. Second Edition, revised and enlarged. With numerous illustration 
one very handsome octavo volume, cloth, $2 75. 



In 



For those, however, who must assume the care of 
diseases and injuries of the eye, and who are too 
much pressed for time to study the classic works on 
the subject, or those recently published by Stellwag, 
Wells, Bader, and others, Mr. Laurence will prove a 
safe and trustworthy guide. He has described in this 



edition those novelties which have secured the confi- 
dence of the profession since the appearance of his 
last. The volume has been considerably enlarged 
and improved by the revision and additions of its 
author, expressly for the American edition.— Am. 
I Journ. Med. Sciences, Jan. 1870. 



30 Henry C. Lea's Publications. — (Surgery, &c). 

rpHOMPSON(SIR HENRY), 

■* Surgeon and Professor of Clinical Surgery to University College Hospital. 

LECTURES OjST DISEASES OF THE URINARY ORGANS. With 

illustrations on wood. Second American from the Third English Edition. In one neat 

octavo volume. Cloth, $2 25. (Just issued.) 
My aim has been to produce in the smallest possible compass an epitome of practical knowl- 
edge concerning the nature and treatment of the diseases which form the subject of the work ; 
and I venture to believe that my intention has been more fully realized in this volume than in 
either of its predecessors. — Author's Preface. 



JDT THE SAME AUTHOR. 

ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 

THE URETHKA AND URINARY FISTULA. With plates and wood-cuts. From the 
third and revised English edition. In one very handsome octavo volume, cloth, $3 50. 
(Lately Published.) 

T)Y THE SAME AUTHOR. (Just Issued.) 

THE DISEASES OF THE PROSTATE, THEIR PATHOLOGY 

AND TREATMENT. Fourth Edition, Revised. In one very handsome octavo volume of 
355 pages, with thirteen plates, plain and colored, and illustrations on wood. Cloth, $3 75. 



/TAYLOR {ALFRED S.), M.D., 

•*■ Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital 

MEDICAL JURISPRUDENCE. Seventh American Edition. Edited 

by John J. Reese, M.D., Prcf. of Med. Jurisp. in the Univ. of Penn. In one large 
octavo volume of nearly 900 pages. Cloth, $5 00; leather, $6 00. (Just Issued.) 

In preparing for the press this seventh American edition of the " Manual of Medical Jurispru- 
dence" the editor has, through the courtesy of Dr. Taylor, enjoyed the very great advantage of 
consulting the sheets of the new edition of the author's larger work, " The Principles and Prac- 
tice of Medical Jurisprudence," which is now ready for publication in London. This has enabled 
him to introduce the author's latest views upon the topics discussed, which are believed to bring 
the work fully up to the present time. 

The notes of the former editor, Dr. Hartshorne, as also the numerous valuable references to 
American practice and decisions by his successor, Mr. Penrose, have been retained, with but few 
slight exceptions ; they will be found inclosed in brackets, distinguished by the letters (H.) and 
(P.). The additions made by the present editor, from the material at his command, amount to 
about one hundred pages; and his own notes are designated by the letter (R.). 

Several subjects, not treated of in the former edition, have been noticed in the present one, 
and the work, it is hoped, will be found to merit a continuance of the confidence which it has so 
long enjoyed as a standard authority. 

j$Y THE SAME AUTHOR. (Now Ready.) 

THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- 
DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo 
volumes, cloth, $10 00; leather, $12 00. 

This great work is now recognized in England as the fullest and most authoritative treatise on 
every department of its important subject. In laying it, in its improved form, before the Ameri- 
can profession, the publisher trusts that it will assume the same position in this country. 

TftY THE SAME AUTHOR. New Edition— Now Ready. 

POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND 

MEDICINE. Third American, from the Third and Revised English Edition. In one 
large octavo volume of 850 pages ; cloth, $5 50 ; leather, $6 50. 
This work, which has been so long recognized as a leading authority on its important subject, 
has received a very thorough revision at the hands of the author, and may be regarded as a 
new book rather than as a mere revision. He has sought to bring it on all points to a level 
with the advanced science of the day; many portions have been rewritten, much that was of 
minor importance has been omitted, and every effort made to condense a complete view of the 
subject within the limits of a single volume. Dr. Taylor's position as an expert has brought 
him into connection with nearly all important cases in England for many years. He thus speaks 
with an authority that few other living men possess, while his intimate acquaintance with the 
literature of toxicology on both sides of the Atlantic, renders his work equally adapted as a 
text-book in this country as in Great Britain. 

• 
CONTENTS. 

Poisons.— Absorption and Elimination— Detection— Action— Influence of Habit— Classifica- 
tion of Poisons— Evidence of Poisoning— Diseases resembling Poisoning— Inspection of the Dead 
Body— Objects of Chemical Analysis— Moral and Circumstantial Evidence in Poisoning, Ac. <fcc. 

Irritant Poisons.— Mineral Irritants— Acid Poisons— Alkaline Poisons— Non-Metallic Irri- 
tants—Metallic Irritants— Vegetable Irritants— Animal Irritants. 

Neurotic Poisons.— Cerebral or Narcotic Poisons— Spinal Poisons— Cerebro-Spinal Poisons— 
Cerebro-Cardiac Poisons. 



Henry 0. Lea's Publications — {Psychological Medicine, &c). 31 



qiUKE {DANIEL HACK), M.D., 

J- Joint author of " The Manual of Psychological Medicine," &e. 

ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON 

THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the 
Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. (Just Issued.) 
The object of the author in this work has been to show not only the effect of the mind in caus- 
ing and intensifying disease, but also its curative influence, and the use which may be made of 
the imagination and the emotions as therapeutic agents. Scattered facts bearing upon this sub- 
ject have long been familiar to the profession, but no attempt has hitherto been made to collect 
and systematize them so as to render them available to the practitioner, by establishing the seve- 
ral phenomena upon a scientific basis. In the endeavor thus to convert to the use of legitimate 
medicine the means which have been employed so successfully in many systems of quackery, the 
author has produced a work of the highest freshness and interest as well as of permanent value. 



T>LANDFORD {G. FIELDING), M. D., F. R. G P., 

JL* Lecturer on Psychological Medicine at the School of St. George's Hospital, &c. 

INSANITY AND ITS TREATMENT: Lectures on the Treatment, 

Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the 
United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very 
handsome octavo volume of 471 pages; cloth, $3 25. 
This volume is presented to meet the want, so frequently expressed, of a comprehensive trea- 
tise, in moderate compass, on the pathology, diagnosis, and treatment of insanity. To render it of 
more value to the practitioner in this country, Dr. Ray has added an appendix which affords in- 
formation, not elsewhere to be found in so accessible a form, to physicians who may at any moment 
be called upon to take action in relation to patients. 



It satisfies a want which mast have been sorely 
felt by the busy general practitioners of this country. 
It takes the form of a manual of clinical description 
of the various forms of insanity, with a description 
of the mode of examining persons suspected of in- 
sanity. We call particular attention to this feature 
of the book, as giving it a unique value to the gene- 
ral practitioner. If we pass from theoretical conside- 
rations to descriptions of the varieties of insanity as 



actually seen in practice and the appropriate treat- 
ment for them, we find in Dr. Blandford's work a 
considerable advance over previous writings on the 
subject. His pictures of the various forms of mental 
disease are so clear and good that no reader can fail 
to be struck with their superiority to those given in 
ordinary manuals in the English language or (so far 
as our own reading extends; in any other. — London 
Practitioner, Feb. 1871. 



w- 



INSLOW {FORBES), M.D., D.G.L., frc. 

ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS 

OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- 
phylaxis. Second American, from the third and revised English edition. In one handsome 
octavo volume of nearly 600 pages, cloth, $4 25. 



EA {HENRY C). 

'SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF 

LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Second Edition, 
Enlarged. In one handsome volume royal 12mo. of nearly 500 pages; cloth, $2 75. 
(Lately Published.) 



We know of no single work which contains, in so 
•mall a compass, so much illustrative of the strangest 
operations of the human mind. Foot-notes give the 
authority for each statement, showing vast research 
and wonderful industry. We advise our confreres 
to read this book and ponder its teachings. — Chicago 
Med. Journal, Aug. 1870. 

As a work of curious inquiry on certain outlying 
points of obsolete law, "Superstition and Force" is 
one of the most remarkable books we have met with. 
— London Athenaeum, Nov. 3, 1866. 

He has thrown a great deal of ligh t upon what must 
be regarded as one of the most instructive as well as 



interesting phases of human society and progress. . . 
The fulness and breadth with which he has carried 
out his comparative survey of this repulsive field of 
history [Torture], are such as to preclude our doing 
justice to the work within our present limits. Bat 
here, as throughout the volume, there will be found 
a wealth of illustration and a critical grasp of the 
philosophical import of facts which will render Mr. 
Lea's labors of sterling value to the historical stu- 
dent.— London Saturday Review, Oct. 8, 1870. 

As a book of ready reference on the subject, it is of 
the highest value. — Westminster Review, Oct. 1867. 



TOY THE SAME AUTHOR. (Lately Published.) 

STUDIES IN CHURCH HISTORY 

PORAL POWER— BENEFIT OF CLERGY 
12mo. volume of 516 pp. cloth, $2 75. 
The story was never told more calmly or with 
greater learning or wiser thought. We doubt, indeed, 
if any other study of this field can be compared with 
this for clearness, accuracy, and power. — Chicago 
Examiner, Dec. 1870. 



THE RISE OF THE TEM- 

EXCOMMUNICATION. In one large royal 



Mr. Lea's latest work, ' ' Studies in Church History," 
fully sustains the promise of the first. It deals with 
three subjects — the Temporal Power, Benefit of 
Clergy, and Excommunication, the record of which 
has a peculiar importance for the English student, and 
is*a chapter on Ancient Law likely to be regarded as 
final. We can hardly pass from our mention of such 
works as these — with which that on "Sacerdotal 
Celibacy" should be included — without noting the 



literary phenomenon that the head of one of the first 
American houses is also the writer of some of its most 
original books. — London Athenceum, Jan. 7, 1S71. 

Mr. Lea has done great honor to himself and this 
country by the admirable works he has written on 
ecclesiologicaland cognate subjects. We have already 
had occasion to commend his "Superstition and 
Force" and his "History of Sacerdotal Celibacy." 
The present volume is fully as admirable in its me- 
thod of dealing with topics and in the thoroughness — 
a quality so frequently lacking in American authors — 
with which they are investigated. — N. Y. Journal of 
Psychol. Medicine, July, 1870. 



32 



Henry C. Lea's Publications. 



INDEX TO CATALOGUE 



American Journal of the Medical Sciences 
Abstract, Half-Yearly, of tbe Med Sciences 
Anatomical Atlas, by Smitb and Horner 
Anderson on Diseases of the Skin 
Ashton on the Rectum and Anus . 
Attfield's Chemistry .... 
Ashwell on Diseases of Females . 
Ashhurst's Surgery .... 

Barnes on Diseases of Women 
Bellamy's Surgical Anatomy 
Bryant's Practical Surgery . 
Bloxam's Chemistry • 
Blandford on Insanity .... 
Basham on Renal Diseases . 
Brinton on the Stomach 
Bigelow on the Hip 
Barlow's Practice of Medicine 
Bowman's (John E.) Practical Chemistry 
Bowman's (John E.) Medical Chemistry 
Brunton's Materia Medica 
Bumstead on Venereal .... 
Bumstead and Cullerier's Atlas of Venereal 
Carpenter's Human Physiology . 
Carpenter's Comparative Physiology . 
Carpenter on tbe Use and Abuse of Alcohol 
Chambers on Diet and Regimen 
Chambers's Restorative Medicine 
Christison and Griffith's Dispensatory 
Churchill's System of Midwifery . 
Churchill on Puerperal Fever 
Condie on Diseases of Children . 
Cooper's (B. B.) Lectures on Surgery . 
Cullerier's Atlas of Venereal Diseases 
Cyclopedia of Practical Medicine . 
Dalton's Human Physiology . 
Davis' Clinical Lectures 
Dewees on Diseases of Females . 
Dewees on Diseases of Children . 
Druitt's Modern Surgery 
Dunglison's Medical Dictionary . 
Dunglison's Human Physiology . 
Dunglison on New Remedies 
Ellis's Medical Formulary, by Smith . 
Erichsen's System of Surgery 
Fenwick's Diagnosis .... 
Flint on Respiratory Organs . 

Flint on the Heart 

Flint's Practice of Medicine . 

Flint's Essays 

Flint on Phthisis . 

Fownes's Elementary Chemistry . 

Fox on Diseases of the Stomach . 

Fulleron the Lungs, &c. 

Green's Pathology and Morbid Anatomy 

Gibson's Surgery 

G luge's Pathological Histology, by Leidy 
Galloway's Qualitative Analysis . 

Gray's Anatomy 

Griffith's (R. E.) Universal Formulary 
Gross on Foreign Bodies in Air-Passages 
Gross's Principles and Practice of Surgery 
Guersant on Surgical Diseases ol Children 
Hamilton on Dislocations and Fractures 
Hartshorne's Essentials of Medicine . 
Hartshorne's Conspectus of the Medical Scie 
Hartshorne's Anatomy and Physiology 
Heath's Practical Anatomy . 
Hoblyn's Medical Dictionary 

Hodge on Women 

Hodge's Obstetrics 

Hodges' Practical Dissections 
Holland's Medical Notes and Reflections 

Holmes's Surgery 

Horner's Anatomy and Histology 
Hudson on Fevers .... 

Hill on Venereal Diseases 
Hillier's Handbook of Skin Diseases 
Jones (C. Handfleld) on Nervous Disorders 



PAGE 
. 1 

3 

6 

20 
28 
in 
2:s 

27 
28 
7 
29 
U 
3] 
18 
16 
28 
14 
II 
i I 
14 
19 
19 



Kirkes' Physiology .... 

Knapp's Chemical Technology 

Lea's Superstition and Force 

Lea"8 Studiesin Church History . 

Lee on Syphilis ..... 

Lincoln on Electro-Therapeutics . 

Leishinan's Midwifery .... 

La Roche on Yellow Fever . 

La Roche on Pneumonia, &c. 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye .... 

Laycock on Medical Observation . 

Lehmann's Physiological Chemistry, 2 vols 

Lehmann's Chemical Physiology . 

Ludlow's Manual of Examinations 

Lyons on Fever .... 

Maclise's Surgical Anatomy . 

Marshall's Physiology . 

Medical News and Library . 

Meigs on Puerperal Fever 

Miller's Practice of Surgery . 

Miller's Principles of Surgery 

Montgomery on Pregnancy . 

Neill andJSmith's Compendium of Med. Science . 

Neligan's Atlas of Diseases of the Skin 

Neligan on Diseases of the Skin . 

Obstetrical Journal . 

Odling's Practical Chemistry 

Parry on Extra-Uterine Pregnancy 

Pavy on Digestion 
I Pavy on Food 

Parrish's Practical Pharmacy 

Pirrie's System of Surgery . 

Pereira's Mat. Medica and Therapeutics, abridged 

Quain and Sharpey's Anatomy, by Leidy 

Roberts on Urinary Diseases . 

Ramsbotham on Parturition . 

Rigby's Midwifery 

Rodwell's Dictionary of Science . 

Swayne's Obstetric Aphorisms 

Sargent's Minor Surgery 

Sharpey and Quain's Anatomy, by Leidy 

Skey's Operative Surgery 

Slade on Diphtheria .... 

Smith (J. L.) on Children 

Smith (H. H.) and Horner's Anatomical Atlas 
Smith (Edward) on Consumption . 

Smith on Wasting Diseases in Children 

Stille's Therapeutics .... 

Sturges on Clinical Medicine 

Stokes on Fever ..... 

Tauuer's Manual of Clinical Medicine . 

Tanner on Pregnancy 

Taylor's Medical Jurisprudence 

Taylor's Principles and Practice of Med J 

Taylor on Poisons . 

Tuke on the Influence of the Mind 

Thomas on Diseases of Females . 

Thompson on Urinary Organs 

Thompson on Stricture . 

Thompson on the Prostate 

Todd on Acute Diseases . 

Walshe on the Heart 

Watson's Practice of Physic 

Wells on the Eye . 

West on Diseases of Females 

Weston Diseases of Children 

West on Nervous Disorders of Children 

What to Observe in Medical Cases 

Williams on Consumption 

Wilson's Human Anatomy . 

Wilson on Diseases of the Skin 

Wilson's Plates on Diseases of the Skin 

Wilson's Handbook of Cutaneous Medicine 

Winslow on Brain and Mind 

Wohler's Organic Chemistry 

Winckel on Childbed 

Zeissl on Venereal . 



isp 



For "The Obstetrical Journal," Five Dollars a year, see p. 22. 



OCT -0 ISM 



